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Full text of "The American journal of the medical sciences"

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THE 



AMERICAN JOURNAL 



OF THE 



MEDICAL SCIENCES. 



EDITED BY 



ISAAC HAYS, M.D., 

PELI.OWOP rnE COI.LIiUE OF pursier ANS OF PHILADELPHIA ; MEMBER OF 

THE ACADEMY OF NATURAL SCIENCES OF PHILADELPHIA, AND OF THE AMERICAN 

PHILOSOPHICAL SOCIETY ; ASSOCIATE FELLOW OF THE AMERICAN 

ACADEMY OF ARTS AND SCIENCES, 

&C. &C. &C. 



ASSISTED BY 

I. MINIS HAYS, M.D. 



NEW SERIES. 
VOL. LXXI. 




PHILADELPHIA: 

HENRY C. LEA. 

1876. 



II 

V.7/ 



Entered according to the Act of Congress, in the year 1876, by 

HENRY C. LEA. 
in the Office of the Librarian of Congress. All rights reserved. 



PHILADELPHIA: 
COL LI X 9, PRINTKR, 

705 Jayne Street. 



TO READERS AND CORRESPONDENTS. 

All communications intended for insertion in the Original Department of this 
Journal are only received for consideration with the distinct understandinji' that 
they are sent for publication to this Journal alone, and that abstracts of them 
shall only appear elsewhere subse(|uently, and with due credit. Gentlemen 
favouring us with their communications are considered to be bound in honour 
to a strict observance of this understanding. 

Contributors who wish their articles to appear in the next number are re- 
quested to forward them before the 1st of February. 

Compensation is allowed for original articles and reviews, except when illus- 
trations or extra copies are desired. A limited number of extra copies (not 
exceeding _/(//'//) will be furnished to authors, provided the request for them 
be made at the time the communication is sent to the Editors. 

The following works have been received : — 

Stiuii ed Osservazioni Intorno ni Malati accolti in un Quinquennio Nella Clinica 
Medica di Firenze, Diretta Ual Prof. Pietro Ciprani per il Dott. Gaetano Lkopardi, 
ainto alia Cattedra Luddetta. Vol.1. — Malattie Costituzionali. Firetize: G. Bar- 
bera, 1875. 

Embolia dell' Arteria Ceutrale della Retina Circolazione Collaterale. Storia 
Clinica Annotata dal Dott. Gottaroi. Roma, 1875. 

Galeui Libellus quo Uemonstratur Optimum Medicum eundem esse Philosophum. 
Recognovit et enarravit Iwanus MnKLMCR, Litt. Grsec. et Rom. in Universitate 
Erbmgensi, Prof. P. 0. Erlaiigen : A. Deicherti, 1875. 

Discours prononc^ a I'Acaderaie de M^decine dans la Discussion sur le Cholera, 
par M. BoNNAFO.NT. Paris: Moquet, 1875. 

Transactions of the Pathological Society of London. Vol. XXVI. London, 1875. 

Medico-Chirurgical Transactions. Published by the Royal Medical and Chirurgi- 
cal Society of London. V^ol. LVIII. Loudon: Longmans, 1875. 

Lectures on Dermatology ; delivered in the Royal College of Surgeons of England 
in 1874-1875. By Erasmus Wilson, F.R.S., F.R.C.S., Member of Council, and 
Prof, of Dermatology. London: J. &; A. Churchill, 1875. 

Outlines of Practical Histology ; being the Notes of the Histological Section of 
the Class of Practical Physiology, held in the University of Edinburgh. By Wil- 
liam RuTHKRFORU, M.D., F.K.S.E., Prof, of Institutes of Med. in Univ. of Edin. 
London: J. & A. Churchill, 1875. 

Experimental Investigation of the Action of Medicines. By T. Lauder Biiun- 
Tox. M.D , Sc.D., F.R.S. London: .J. & A. Churchill, 1875. 

Clinical and Physiological Researches on the Nervous System. No. 1. — On the 
Localization of Movements in the Brain. By J. Hughli.ngs Jackson, M.D., Phys. 
to London Hospital, etc. London: J. & A. Churciiill. 

Memorials of Harvey ; including a Letter and Autographs in Fac-simile. Col- 
lected and edited by J. H. Aveling. London: J. & A. Churchill, 1875. 

A Practical Treatise on Diseases of the Eye. By Robert Brudenkll Carter, 
F.R.C.S., Ophthalmic Surgeon to St. George's Hospital, etc. London: Macmillan 
& Co., 1875. 

Lectures and Essays on the Science and Practice of Surgery. Bj' Robert 
McDonnell, .M.D., F.R.S. , President of Pathological Society of Dublin. Part II.— 
The Physiology and Pathology of the Spinal Cord. Dublin : Faniiin & Co., 1875. 

A Physician's Notes on Ophthalmology. Second series. By J. Hughlings Jack- 
son, M.D., F.R.C.P. 

A Treatise on Human Physiology; designed for the use of Students and Prac- 
titioners of Medicine. By John C. Dalton, M.D., Prof, of Physiology and Hygiene 
in the Coll. of Phys. and Surgeons, New York, etc. Sixth edition, revised and 
enlarged. Phihulelphia: Henry C. Lea, 1875. 

Lectures on Syphilis, and on Some Forms of Local Disease aflFecting principally 
the Organs of Generation. By Henry Lee, Prof, of Surgery at Royal Coll. of Sur- 
geons of Englaml, etc. Philadelphia: Henry C. Lea, 1875. 

Phthisis: its Morbid Anatomy, Etiology, Symptomatic Events and Complications, 
Vitality and Prognosis, Treatment and Ph3'sical Diagnosis. In a Series of Clinical 
Studies. By Austin Flint, M.D., Prof, of Prin. and Prac. of Med., and of Clin. 
Med., in Bellevue Hosp. Med. Coll., New York. Philadelphia: Henry C. Lea, 1875. 



8 TO READERS AND CORRESPONDENTS. 

A System of Miilwil'ery, including the Diseases of Pregnancy and the Puerperal 
State. By William Leishmax, M.D., Regius Prof, of Midwifery in Univ. of Glas- 
gow. Second Americau from second and revised English edition. With additions 
by John S. Parry, M.D., Obstetrician to the Philadelphia Hospital, etc. Philadel- 
phia : Henry C. Lea, 1875. 

A Manual of Minor Surgery and Bandaging. By Christopher Heath, F.R.C.S., 
Surg, to Univ. Coll. Hosp., etc. Fifth edition. Philadelphia: Lindsay & Blakis- 
ton, 1875. 

The Physician's Visiting List for 1876. Philadelphia: Lindsay & Blakiston. 

The Student's Guide to Human Osteology. By W. W. WagstafiFe, B.A., F.R.C.S., 
Assist. Surgeon to, and Lecturer on Anatomy at St. Thomas's Hospital. Philadel- 
phia: Lindsay & Blakiston, 1875. 

Atlas of Skin Diseases: consisting of a series of Coloured Illustrations, together 
with Descriptive Test and Notes upon Treatment. By Txlburt Fox, M.D., Phys. 
to Dept. for .Skin. Dis. in University Coll. Hosp. Part I. Philadelphia : Lindsay & 
Blakiston, 187G. 

Illustrations of Clinical Surgery; consisting of Plates, Photographs, Woodcuts, 
Diagrams, etc., with Descriptive Letter-press. By Jonathan Hutchinson, F.R.C.S., 
Surgeon to London Hospital, etc. Philadelphia: Lindsay & Blakiston, 1875. 

Lectures on Diseases of the Nervous System. By Jerome K. Baudut, M.D., 
Prof, of Psychological Med. and Dis. of Nervous System in Missouri Med. Coll., etc. 
Reported by V. Biart, M D. Revised and edited by the author. Philadelphia: 
J. B. Lippincott & Co., 187G. 

A Treatise on Therapeutics, comprising Materia Medica and Toxicology, with 
especial reference to the Application of the Physiological Action of Drugs to Clini- 
cal Medicine. By H. C. Woou, Jr., M.D., Prof, of Botany, and Clin. Prof, of Dis. 
of Nervous .System in Univ. of Penna., etc. Second edition, I'evised and enlarged. 
Philadelphia : J. B. Lippincott & Co., 1875. 

Hospital Plans: Five Essa_ys relating to the Construction, Organization, and 
Management of Hospitals, contributed by their authors for the use of the Johns 
Hopkins Hospital of Baltimore. New York: William Wood & Co., 1875. 

Cyclopoedia of the Practice of Medicine. Edited by Dr. H. von Ziemssen. 
Vol. V. — Diseases of the Respiratory Organs, by Prof. Juergexsex, of Tubingen; 
Prof. Hertz, of Amsterdam ; Prof. Ruehle, of Bonn ; and Prof. Rinpfleisch, of 
Wurtzberg. Albert H. Buck, M.D., New York, Editor of Americau edition. New 
York: William Wood & Co., 1875. 

A Text-Book of Human Physiology: designed for the use of Practitioners and 
Students of Medicine. By .Austin Flint, Jr., M.D., Professor of Physiology and 
Physiological Anatomy in Bellevue Hosp. Med. Coll., New York, etc. New York : 
D. Appleton & Co.. 18^6. 

On the Relation between Diabetes and Food, and its Application to the Treatment 
of the Disease. By Arthur Scott Donkin, M.D., Edinburgh. New York: G. P. 
Putnam's Sons. 1875. 

A Series of American Clinical Lectures. Edited by E. C. Seguin, M.D. Vol. I., 
No. 9 — Peritonitis, by Prof. .Alfred L. Loomis. New York: G. P. Putnam's Sons, 
1875. 

Cholera Epidemic of 1873 in the United States; the Introduction of Epidemic 
Cholera through the Agency of the Mercantile Marine ; Suggestions of Measures of 
Prevention. By John M. Woodworth. M.D., Supervising Surgeon U. S. [Merchant] 
Marine Hospital Service Washington: Government Printing Office, 1875. 

Annual Report of the Supervising Surgeon of the Marine Hospital Service of the 
United States for the fiscal year 1874. By John M. Woodworth, M.D. Govern- 
ment Printing Office, 1874. 

A Report on a Plan for Transporting Wounded Soldiers by Railwaj' in time of 
War; with Descriptions of Various Methods employed for this purpose on diflFerent 
occasions. By George A. Otis, Assist. Surgeon U. S. A. Washington, 1875. 

Hints on the Obstetric Procedure. By William B. Atkinson. M.D., Phys. to 
Dept. of Obstetrics and Dis. of Women, Howard Hospital, Phila. Philadelphia, 1875. 

Statistics of Mortality from Pulmonary Phthisis in the United States and in 
Europe. By William Gleitsmann, M.D., of Baltimore. Baltimore: Turnbull 
Brothers, 1875. 

On Altitude and Climate in the Treatment of Pulmonai-y Phthisis. By W. Gleits- 
HAKN, M.D. Baltimore, 1875. 



TO READERS AND CORRESPONDENTS. y 

Scnrlntina Statistics of the Uuited States. Mikor. Cincinnati : Pvobeit Cl.arke & 
Co., 1875. 

Lecture upon Grnnulfitions of the Conjunctiva. By Dr. Sicdel, fils, Pnris. 

\ Study of the Normal Movements of the Unimpregnated Uterus. By Ely Van 
DE Wauker, M I).. Syracuse. New York, 1875. 

Report on Diseases of Women. For 1874. By Vail F. Mund£, M.D. New 
York. 1875. 

Hospital Construction. By Edw-ivrd Hutchison, M.D. 

A Rare Form of Monstrosity. Two Cases of apparently True Hemaphroditism. 
By W. L. Richardson, M.D., Visiting Phys. to Boston Lying-in Hospital, and 
Thomas Dwight, Jr., >rD., Prof, of Anatomy at Medical School of Maine. Cam- 
bridge, 1875. 

The Contagium Particles of the Eruptive Contagious Fevers; their Nature and 
Mode of Action. By L E Atkinson, M.D. Baltimore, 1875. 

The History of Anesthesia. By Euward S. Dunster, M.D., Prof, of Obstet. in 
Univ. of .Mich. Ann .\rbor. 1875. 

The Microscope in Gynecology. By A. Mead Edwards, M.D. Newark, 1875. 

Anesthesia and Anaesthetics. By J. Vi'. Trader, Sedalia, Mo. 

Manitou, Colorado ; its Mineral Waters and Climate. By S. Edwin Solly, 
M.R.C.S., Eng. St. Louis, 1875. 

What Course should be Pursued with an Eye lost through Accident? By Julian 
J. Chisolm, M.D., Prof, of Eye and Ear Surg, in Univ. of Md. Baltimore, 1875. 

History of .American Medical Literature from 177G to the Present Time. By S. 
D. Gross, ^LD., LL.D., D.C.L. Oson., Prof, of Surgery in the Jeflerson Medical 
College. Philadelphia, 1876. 

The Dangers of the Transmission of Syphilis between Nursing Children and 
Nurses in Infant Asylums and in Private Practice. By. R. W. Taylor, M.D., Sur- 
geon to New York Dispensary. New York: William W'ood & Co., 1875. 

Abortion; its Causes and Treatment. By Walter Coles, M.D. St. Louis, 1875. 

Physiological Action of Lycoctonia. By Isaac Ott, M.D., Demonstrator of Physi- 
ology, Univ. of Penna. 

State Medicine, in its Relations to Insanity. By Dr. Nathan Allen, of Lowell, 
Mass. Boston, 1875. 

Are Carbolic Acid Disinfections useful in Yellow Fever ? By Dr. S. R. Le ]\[on- 
NiER, of New Orleans. 

Reports of Sixteen Cases of Cataract Operations. By B. Joy Jeffries, M.D., of 
Boston. 

Our Teeth and their Preservation. By L. P. Meredith, M.D., D.D.S. Cincin- 
nati, 1875. 

Observations upon Two Cases of Fibroma Molluscum. By J. E. Atkinson, M.D. 
New York, 1875. 

Climatological and Sanitary Report of Florida. By John P. Wall, of Tampa. 
Philadelphia, 1875. 

Menstruation, and the Law of Monthly Periodicity. By J. Goodman, M.D., Prof, 
of Obstetrics in Louisville Med. Coll. Louisville, 1875. 

The Sanitary Condition of Boston. The Report of a Medical Commission appointed 
by the Board of Health of the City of Boston to investigate the Sanitary Conditions 
of the City. Boston, 1875. 

The Address in Obstetrics and Diseases of Women and Children. By W^m. H. 
Byford, A.M., M.D. Philadelphia, 1875. 

Transactions of the Medical Association of .A.labama, April, 1875. Montgomery. 

Transactions of Medical and Chirurgical Faculty of Maryland, 1875. Baltimore. 

Transactions of the Medical Society of West Virginia, 1875. Wheeling, 1875. 

Transactions of Medical Society of District of Columbia. July and Oct.. 1875. 

Transactions of the Michigan State .Medical Society, 1875. Lansing, 1875. 

Transactions of the New Hampshire Medical Society, 1875. Concord, 1875. 

Transactions of the Indiana State Medical Society, 1875. Indianapolis, 187-5. 

Transactions of the Minnesota State Medical Society, 1875. Minneapolis, 1875. 

Transactions of Medical Society of Pennsylvania, 1875. Philadelphia, 1875. 

Transactions of the Kansas j\ledical Society, 1875. Topeka, 1875. 

Transactions of the American Otological Society, Newport, 1875. 

Proceedings of Academy of Natural Sciences of Philadelphia, May to Sept., 187^ 

Statistics of Births, Marriages, and Deaths in the City of Philadelphia for the 



10 TO READERS AND CORRESPONDENTS 

year 1874. Compiled by William H. Ford, M.D., Secretary of the Board of 
Health. Philadelphia, 1875. 

Report of the Health Officer of the City and County of San Francisco, Henry Gib- 
bons, Jr., M.D., Health Officer. San Francisco, 1875. 

Report of the Board of Health of the City of St. Louis. St. Louis, 1875. 

Annual Report of the Surgeon-General United States Army, 1875. 

A Supplement to the late Asylum Controversy, by Members of the Medical So- 
ciety of Washington Territory. Olympia, W. T., 1875. 

Report of the Illinois State Hospital for the Insane. Jacksonville, 1875. 

Report of the State Lunatic Hospital of Pennsylvania. Harrisburg, 1875. 

The Annual Address before the Cincinnati Medical Society by the retiring Presi- 
dent, And. C. Kemper, A.M., M.D., October, 1875. 

The following Journals have been received in exchange: — 
Medizinische Jahrbi'icher. Heft. II. und III., 1875. 
Deutsches Archiv fiir Klinische Medicin. Bd. XVI., Heft 'I. 
Archiv der Heilkunde. Bd. XVII., Erstes Heft. 
Centralblatt fiir die Medicinische Wissenschaften. Nos. 40 to 51. 
AUgemeine Wiener Medizinische Zeitung. Nos. 37 to 47. 
Deutsche JNIedicinische Wochenschrift. September 25, 1875. 
Bibliothek for Lceger. Bd. 5, Heft. 4. 
Nordiskt Medicinskt Arkiv. Sjunde Bd. Tredje Haftet. 
L'Imparziale. Nos. 18 to 22. 
Lo Sperimentale. Fascic. 9, 10. 
Correio Medico de Lisboa. Nos. 2 to 8. 

Archives G^niSrales de Medecine. Octobre, Novembre, Decembre, 1875. 
Revue des Sciences Medicales en France et I'Etrauger. Octobre, 1875. 
Archives de Physiologie Normale et Pathologique. Aout, Septembre, 1875. 
Annales de Dermatologie et de Syphiligraphie. No. 6, 1874-75. 
Annales des Maladies de I'Oreille et du Larynx. Novembre, 1875. 
Gazette Hebdomadaire de !\I6decine et de Chirurgie. Nos. 38 to 49. 
L'Union M6dicale. Nos. 109 to 143. 
Le Mouvement Medical. Nos. 38 to 49. 
La Tribune M^dicale. Nos. 370 to 380. 
Le Progres Medical. Nos. 36 to 45. 

Revue Scientifique de la France et de I'Etranger, Nos. 12 to 23. 
The British and Foreign Medico-Chirurgical Review. October, 1875. 
The Lancet. October, November, December, 1875. 

The Medical Times and Gazette. October, November, December, 1875. 
The British Medical Journal. October, November, December, 1875. 
The London Medical Record. October, November, December, 1875. 
The Sanitary Record. October, November, December, 1875. 
The Practitioner. October, November, December, 1875. 
The Royal London Ophthalmic Hospital Reports. September, 1875. 
Edinburgh Medical Journal. October, November, December, 1875. 
The Glasgow Medical Journal. October, 1875. 

The Dublin Journal of Medical Science. September, October, November, 1875. 
The Indian Medical Gazette. September, October, 1875. 
Canada Medical and Surgical Journal. October, November, December, 1875. 
The Canada Medical Record. October, December, 1875. 
L'Union M^dicale du Canada. Septembre, October, November, 1875. 
The usual American exchanges have been received; their individual acknow- 
ledgment is omitted from want of space. 



Communications intended for publication, and books for review, should be sent 
frez of expense, directed to Isaac Hats, M.D., Editor of the American Journal of the 
Medical Sciences, care of Mr. Henry C. Lea, Philadelphia. Parcels directed as 
above, and (carriage paid) under cover, to Mr. Charles J. Skeet, Bookseller, No. 10 
King William Street, Charing Cross, London, will reach us safely and without delay. 

All remittances of money and letters on the business of the Journal should be ad- 
dressed exclusively to the publisher, Mr. H. C. Lea, No. 706 Sansom Street. 

The advertisement sheet belongs to the business department of the Journal, and 
all communications for it must be made to the publisher. 



CONTENTS 

OF THE 

AMERICAN JOURNAL 

OF THK 

MEDICAL SCIENCES. 

NO. CXLI. NEW SERIES. 

JANUARY, 1876. 



ORIGINAL COMMUNICATIONS. 

MEMOIRS AND CASES. 

ART. PAGK 

I. The Effect of vSmall Doses of Merourj' in modifying' the number of the 
Red Blood Cori)uscles in Syphilis ; A study of Blood-counting witli the 
Ilematimfetre. By E. L. Keyes, M.D.. Adjunct Professor of Surgery and 
Professor of Dermatology in the Belle vue Hospital Medical College, New 
York, etc. (With two wood-cuts.) ....... 17 

II. A Peculiar and Painful Affection of the Fourth Metatarso-Phalangeal 
Articulation. By Thomas G. Morton. M.D , one of the Surgeons to the 
Pennsylvania Hospital, Surgeon to the Philadelphia Orthojiasdic Hos- 
pital, etc. (With two wood-cuts.) ........ 37 

III. Description of a New Ophthalmoscope and Ophthalmometer, devised 
for Clinical Use and for Physiological and Therapeutic Investigations 
upon iMan and Animals. By Edward 0. Shakespeare, A.M., M.D., of 
Philadelphia. (With four illustrations.) ...... 45 

IV. Double Ovariotomy performed for the removal of Solid Ovarian Tu- 
mours. Transfusion of Milk four days after Operation. By 'J\ Gaillard 
Thomas, M.D., Professor of Obstetrics and Diseases of Women and 
Children in the College of Physicians and Surgeons, New York. . . Gl 

V. A New Mechanical Treatment of Irreducible Flexions of the Uterus. 
By EUerslie AVallace, M.D., Professor of Obstetrics and Diseases of 
Women and Children in Jefferson Medical College, Philadelphia. . . 69 

VI. Endemic of Pythogenic or Miasmatic-Infectious Pneumonia, with 
Illustrative Cases. By W. B. Rodman, M.D., of Frankfort, Ky. . . 76 

VII. On the Pathogenetic Physiology of Follicular Disease of the Throat 
and Air-Passages. By Beverley Robinson, M.D., Surgeon to the Man- 
hattan Eye and Ear Hosp. (Department of the Throat), etc., New York. 84 

VIII. Some Contributions to Operative Surgery. By Jos. C. Hutchison, 
M.D., Surgeon to the Brooklyn (New York) City Hospital, Consulting 
Surgeon to the King's County Hospital. ...... 91 

IX. On the Treatment of Ununited Fracture by " Pressure and Motion," 
with Cases. By Henry H. Smith, M.D., Emeritus Professor of Surgery 

in the University of Pennsylvania. (With four wood-cuts.) . . .94 

X. Relative Mortality of Mariners, Railroad Men, and Travellers. By 
Edgar Holden, M.D., Ph.D, of Newark, N. J 102 



12 CONTENTS. 

ART. PAGE 

XI. Remarkable Case of Traumatic Hypertrophy (includinG: Elongation) 
of Diuital Phalanges. Reported by J. A. Ijippincott, M.D., Late Resi- 
dent Physician at the Pennsylvania Hospital. ..... 113 

XII. Ocelli-ion of the Popliteal Artery, with establishment of the Col- 
lateral Circulation. By Jno. A. Wyeth, M.D., Assistant to the (Jhair 
of Anatomy at the Bellevue Hospital Medical College, New York. 
(With a wood-cut.) 118 

XIII. Case of Hysteria simulating Progressive Locomotor Ataxia. By 

W. H. Webb, M.D., of Philadelphia 119 

XIV. Two Cases of Excision of the Coccygeal Bones for Coccygodynia. 

By Geo. A. Mursick, M.D., of Nyack, N . Y 122 

XV. Five Cases of Chronic Albuminuria treated successfully with large 
doses of Iodide of Potassium. By T. S. Sharpe, M.D., of Natchez, Mis- 
sissippi 124 

XVI. Case of Labour without Liquor Amnii. By Frederick D. Lente, 
M.D., formerly of Cold Spring, N. Y. . . " 125 

A CENTURY OF AMERICAN MEDICINE. 1776-1876. 

XVII. I. Practical Medicine. By Edward H. Clarke, M.D., A. A.S., late 
Professor of Materia Medica in Harvard University. .... 127 

A History of the Discovery of Modern Anasstliesia. By Henry J. Bigelow, 
M.D., Professor of Surgery in Harvard University 164 

REVIEWS. 

XVIII. AVorks of B. A. Morel. 

1. Etudes cliniques sur les Maladies Mentales. 2 vol. 8vo., avec planches. 

18.ol-o2. 

2. Traite des Deg^nerescences physiques, intellectuelles et morales de 

I'Espfece humaine et des causes qui produisent ces varietes maladies, 
avec un atlas de 12 planches, etc. pp. 700. 1857. 

3. Traite des ^laladies mentales. 1 vol. grand 8vo. pp. 866. 1860. 

4. Traite de la Medecine legale des alienes. 1 vol. Svo. pp. 160. 1866. 185 

XIX. Lectures on Syphilis and on some forms of Local Disease affecting 
the Organs of Generation. By Henry Lee, Prof, of Surgery at the Royal 
College of Surgeons of England, Surgeon to St. George's Hospital, etc. 
8vo. pp. 246. Philadelphia: Henry C. Lea, 1875 194 

ANALYTICAL AND BIBLIOGRAPHICAL NOTICES. 

XX. Guy's Hospital Reports. Edited by H. G. Howse, M.S., and Fred- 
erick Taylor, M.D. Third Series. Vol. XX. [With a General Index 
to Vols."XI.-XX.] Svo. pp. xviii., 624. London: J. & A. Churchill, 
1875 203 

XXI. A manual of Diet in Health and Disease. By Thomas King Cham- 
bers, M.D. Oxon., F.R.C.P. Lond., Honorary Physician to H. R. H. the 
Prince of Wales, etc. etc. 8vo. pp. 310. Philadelphia : H. C. Lea, 1875. 214 

XXII. Die Meningitis Tuberculosa der Erwachsenen, Klinisch Bearbeitet. 
Von Dr. Johannes Seitz, Privatdocent an der Uuiversitat Zurich. Svo. 
s. 388. Berlin : August Hirschwald, 1S74. 

The Tubercular Meningitis of Adults. Clinically studied by Dr. Johannes 
Seitz etc. etc. ... . . ...... 219 

XXIII.' Public Health. Reports of the Medical Officer of the Privy 
Council and Local Government Board. New Series, No. II. Supple- 
mentary Report to the l^ocal Government Board on some recent Inqui- 
ries under the Pultlic Health Act, 1858. Presented to both Houses of 
Parliament by command of Her Majesty. Pamphlet, pp. 236. London : 
Printed by George E. Eyre and William Spottiswoode, 1874. . . 221 



CONTENTS. 13 

ART. _ PAGE 

XXIV. Transactions of Amorican State Medical Societies. 

1. Transactions of the Smith Carolina Medical Association, Annual Ses- 

sion, 1875. 8vo. pp. '1~'2. Charleston, 18T.T. 

2. Transactions of the Mediral Society of the State of AVest Virginia. 

8vo. pp. 150. Wheeling. 1H75. 
.3. Transactions of the New Hampshire Medical Society, June, 1875. 
8vo. pp. 109. Concord. 1875. 

4. Transactions of the Medical and Chirurgical Faculty of Maryland. 

April, 1875. 8vo. pp. 226. Baltimore. 1875. 

5. Transactions of the Medical Society of the State of California, 1874 

and 1875. 8vo. pp. 187. Sacramento, 1875. 

6. Transactions of the Minnesota State Medical Society, 1875. 8vo. pp. 

i:W. Minneapolis, 1875. 

7. Transactions of the Michigan State Medical Society, 1875. 8vo. pp. 

85. Lansing. 187.*^. 

8. Transactions of the Indiana State Medical Society, 1875. 8vo. pp. 

184. Indianapolis, 1875. 

9. Transactions of the Medical Association of the State of Alabama, 

1875. 8vo. pp. 359. Montgomery, 1875. ..... 225 

XXV. A Report on a Plan for transporting Wounded Soldiers by Railway 
in time of AVar. with Descriptions of various ]\Iethods employed for this 
purpose on different occasions. By George A. Otis, Assistant Surgeon 
U. S. Army. 8vo. pp. 56. Washington : War Department, Surgeon 
General's Office, 1875 231 

XXVI. Lectures on Diseases of the Nervous System. By Jerome K. 
Bauduy, M.D., Professor of Psychological Medicine and Diseases of the 
Nervous Sj'stem and of Medical Jurisprudence in the Missouri Medical 
College, etc. Reported by V. Biart, M.D.. Revised and Edited by the 
Author. 8vo. pp. 484. Philadelphia: J. B. Lippincott & Co., 1876. . 234 

XXVII. Cyclopaedia of the Practice of Medicine. Edited by Dr. II. von 
Ziemssen. Vol. X. Diseases of the Female Sexual Organs. By Prof. 
Carl Schroeder, of Erlangen, Bavaria. Albert H. Buck, M.D., New 
York. Editor of American Edition. 8vo. pp. viii., 575. New York : 
William Wood & Co., 1875 236 

XXVIII. Lectures on Dermatology, delivered in the Royal College of 
Surgeons of England in 1874, 187,5, including Struma ; Lupus ; Lympha- 
denoma; Xanthoma; Epithelioma; Ichthyosis; Scleriasis ; Verruca; 
Clavus ; Naevus ; Spargosis ; MoUuscum; Cheloma; Prurigo. By 
Erasmus Wilson, F.R.S,, F.R.C.S., Member of Council, and Professor 

of Dermatology. 8vo. pp. 224. London : J. & A, Churchill, 1875. . 241 

XXIX. A Practical Treatise on Fractures and Dislocations. By Frank 
Hastings Hamilton, A..M., M.D.. LL.D., Surgeon to Bellevue Hospital, 
New York, etc. Fifth edition. Revised and Improved, Illustrated with 
344 wood-cuts. 8vo. pp. xxiv., 807. Philadelphia : Henry C. Lea, 1875. 244 

XXX. A Treatise on Human Physiology ; designed for the Use of Students 
and Practitioners of Medicine. By John C. Dalton. M.D., Professor of 
Physiology and Hygiene in the College of Physicians and Surgeons, 
New York, etc. Sixth edition, revised and enlarged. With 316 illus- 
trations. 8vo. pp, 825, Philadelphia : Henry C. Lea, 1875, 

A Text-Book of Human Physiology ; designed for the Use of Practitioners 
and Students of Medicine. By Austin Flint, Jr.. M.D., Professor of Phy- 
siology and Physiological Anatomy in the Bellevue Hospital Medical 
College, New York, etc. Illustrated by three lithographic plates, and 
313 %vood-cuts. 8vo. pp. 978. New York : D. Appleton & Co., 1876. . 246 

XXXI. Vision: its Optical Defects and the Adaptation of Spectacles. 
Embracing, First, Pliysical Optics; Second, Physiological Optics; 
Third, Errors of Refraction and Defects of Accommodation, or Optical 
Defects of the Eye, With Seventy-four Illustrations on Wood, and 
Selections from the Test-Types of Jaeger and Snellen, By C, S. Fenner, 
M.D, 8vo. pp. 299. Philadelphia : Lindsay and Blakiston, 1875. . 248 



14 



CONTENTS. 



ART. PAGE 

XXXII. The Relations of the Nervous Sj"stem to Diseases of the Skin. 
By L. Duncan Bulkley. A.M., M.D., Physician to the Skin Department, 
Demilt Dispensary, New York, etc. etc. Reprinted from the Archives 

of Electrolog-y and Neurology. New York : G. P. Putnam's Sons, 1875. 250 

XXXIII. Report of the Committee appointed by the Board of Public 
Education to Inquire into the Sanitary Condition of the Schools of the 
First School District of Pennsylvania, City of Philadelphia. Pamphlet, 

pp. 37, with 7 plates. Philadelphia, 1875. ...... 251 

XXXI Y. Health Board Reports. 

1. Report of the Board of Health of the City and Port of Philadelphia, 

for 1874. 8vo. pp. 402. 

2. Second Annual Report of the Secretary of the State Board of Health 

of Michigan. Fiscal year ending Sept. 30, 1874. 8vo. pp. xxxiii., 
221. Lansing, 1875 253 



QUAETERLY SUMMARY 



IMPROVEMENTS AND DISCOVERIES IN THE 
MEDICAL SCIENCES. 

Anatomy and Physiology. 



1. On the Yaso-dilator Action of 
the Glosso-pharyngeal Nerve 
on the Vessels of the Mucous 
jMembrane at the Base of the 
Tongue. By A. Vulpian. . 255 



PAGE 

Researches on the Ovary of the 
Foetus and New-born Child. By 
Dr. Haussmann and Dr. Sinety. 255 

Action of Alkalies upon the 
Composition of the Blood. By 
Pupier. ..... 255 



Materia Medica, General Therapeutics, and Pharmacy. 



4. Warburg's Tincture. . . 256 

5. Monobromide of Camphor. By 
Dr. Pathault 257 

6. Salicylate of Soda. By Dr. 
Moeli 257 

7. Effects of certain Cathartic Me- 
dicines on the Biliary Secretion 
of the Dog. By Dr. Rutherford 
and M. Yignal. .... 258 

8. The Physiological Properties of 



Aldehyd. By Drs. Albertoni and 
Lussana 259 

9. Therapeutic Use of Bromhy- 
drate of Quinia. ByProf. Gub- 

ler 260 

10. Hypodermic Injection of Nu- 
tritious Substances. By Dr. 
Kreug. ..... 260 

11. The Question of Transfusion. 

By Prof. P. L. Panum. . .261 



Medical Pathc logy and Therapeutics, and Practical Medicine. 



12. Leukaemia a Primary Blood 
Disease. By Prof. Biesiadecki. 

13. Pathological Anatomy of En- 
demic Malarial Fevers. By 
Prof. Kelsch. .... 

14. The Treatment of Paludal 
Fevers by Arsenic. By M. Sis- 
tach 

] 5. Smallpox of Sheep. By Dr. 
Klein 



! 16 Pathology of Sunstroke. By 
263 j Dr. Rudolph Arndt. 

17. Treatment of Cerebral Rheu- 
matism by Chloral. By M. 
263 I Bouchut. . . . ^ . 

I 18. Artificial Respiration in Ful- 

I minant Apoplexy. By Prof. 
2G4i Schiff. 

j 19. Pathology of Chorea. By Dr. 
265 I W. H. Dickinson. . 



265 



161 



26' 



268 



CONTENTS. 



15 



20. Treatinont of Chorea liy Ether- 
Spray and Ice-Water Lotions 
aloujr the Vertebral Column. By 
Dr. Fabry 270 

21. Nitrite of Amyl in Nervou.s 
CephaUilgia. By Dr. I.ithjrow. 270 

22. Tincture of Gelseminnm iu 
Neuralfria. By Dr. Spencer 
'IMiomson ..... 270 

TA. Bromide of Potassium in Epis- 
taxis, Uterine IIemorrha<j:e, and 
Coryza. By M. Ad. Geneuil . 270 

24. Treatment of Spasmodic Asth- 
ma by the Subcutaneous In- 
jection of Morphia. By Dr. J. 
Keith Anderson. . . . 271 

2.^. Ilheumatic Pleurisy. By Prof. 
Lasegue. ..... 271 

26. Treatment of Acute Sthenic 
Pneumonia with Veratrura. By 
Dr. Th. Sidio 272 

27. Can Tubercular Matter or the 



Flesh of Tuberculous Animals 
communicate or e.xcite Tubercu- 
lar Disease if taken as Food ? By 
Prof. Gurlach 272 

28. Ergot in Haemoptysis. By Dr. 
Jas. M. Williamson. . . 273 

29. Contracted Pupil in Heart Dis- 
ease. By Prof. Giovanni. . 273 

30. Paracentesis of the Pericar- 
dium. By M. H. Roger. . . 274 

31. On Aortic Aneurism in the 
Army, and the conditions asso- 
ciated with it. By Mr. F. H. 
Welch .274 

32. Digestive Power of the Gastric 
Juice in Dyspepsia. By Prof 
Leube 276 

33. Diabetic Phosphaturla. By 

M. J. Teissier. .... 277 

34. Boracic Acid in the Treatment 
of Ringworm. B^ Surgeon- 
Major Watson. . . . 277 



SuROiCAL Pathology and Therapeutics, and Operativk Surgery. 



35. Influence exerted by prior 
Lesions of the Liver on the Pro- 
gress of Traumatic Lesions. By 
Prof. Verneuil. . . .278 

36. Chloral as a Local Application 

to Ulcers. By Mr. Lucas. . 279 

37. Excision of the Thyroid Gland. 

By Dr. Patrick Heron Watson. 280 
•38. A Pistol Ball remaining eigh- 
teen days in the Left Ventricle 
of the Heart. By M. Tillaux. . 282 

39. Urethral Neuropathy. By Dr. 
Bron. . . .' . .282 

40. Chloral as an Application in 
Fissure of the Anus. By Dr. 
Cr6quy 283 



41. Osteoclasis and Osteotomy 
from an Orthopaedic Point of 
View. By Dr. Nepveu. . . 283 

42. On Resection of the Scapula. 

By Dr. Boeckel. . . .284 

43. Improvement on Syme's Ope- 
ration. By Mr. Joseph Bell. . 285 

44. Aortic Aneurism successfully 
treated by the Distal Ligature. 

By Mr. Thos. Annandale. . 285 

45. Ligature of Femoral Artery 
with Carbolized Catgut for Pop- 
liteal Aneurism. By Mr. Holmes. 286 

46. Carbolized Catgut Ligature. . 287 



Ophthalmology. 



47. On the Function of the Ciliary 
Muscle. By Dr. Warlomont. . 



48. Tumours of the Orbit. 
Geo. Lawson. . 



By Mr. 



289 



Midwifery and GYNiECOLOGY. 



49. Prevention and Management 
of Miscarriages. By Dr. A. W. 
Edis 289 

50. Uncontrollable Vomiting of 
Pregnancy cured by Hyoscya- 
mia. By Dr. Pitois. . . 290 

51. Rupture of Uterus. By Bandl. 290 

52. General Dropsy in a Foetus. 

By Mr. Lawson Tait. . . 290 



53. The Dysmenorrhoeal Mem- 
brane. By Dr. P. Finkler. . 291 

.54. Peri-uterine Haematocele after 
Abortion. By Dr. S. Schrank. 291 

55. Ovariotomy complicated with 
Pregnancy and Caesarean Sec- 
tion. By'Mr. Thomas Hillas. . 292 

56. Use of Chloral Hydrate in 
Carcinoma Uteri. By Dr. Fleis- 
cher 292 



16 



OCX TENTS. 



AMERICAN INTELLIGENCE. 



Original Communications. 



Medico-legal Evidence of Indepen- 
dent Life in a New-born Child. 
By J. B. Gaston, M.D. 

Rupture of Uterus at full Terra; 
Child, Placenta, and A.ppen- 
dajres emptied into Peritoneal 
Cavity; Delivery by Version 
through Natural Outlet ; Death 



293 



after sixty hours. By John W. 
Ogilvie, M.D 295 

Hydrate of Chloral in Labour. By 
C. A. Prentiss, M.D. . . 298 

Case of Spontaneous Evolution. 
By J. R. Humphrey, M.D. . 298 

AtropitB Sulphas in Acute Myrin- 
gitis. By A. N. Ellis, M.D. . 299 



Domestic Summary. 



Physiological Action of the Hem- 
lock and its Alkaloid. By Dr. 
B. F. Lautenbach. . . .300 

Physiological Action of Lobelina. 
By Dr. Isaac Ott. . . .301 

Removal of the Entire Arm, Scap- 
ula, and three-fourths of the 
Clavicle, for Osteo-sarcoraa. By 
Dr. A. B. Crosby. . . .301 

Removal of ICntire Upper Jaw for 



Malignant Disease. By Dr. 

Charles B. Brigham. . . 301 

Chronic Subacute Neuritis. By 

Dr. H. M. Bannister. . . 302 

Unusual Terminations of Uterine 

Fibroids. By Dr. Theophilus 

. Parvin 303 

Salicin as an Enteric Tonic and 

Astringent. By Dr. W. H. Vail. 304 
International Medical Congress, 

Philadelphia, 1676. . . .304 



ERRATA. 

Page 26, fourth line from top, /or "0.0006 mm.," rtad "0.006 mm." 

" 28, sixteenth line froiu top, /or "20 syphilitic," read " 21 syphilitic." 



THE 

AMERICAN JOURNAL 
OF THE MEDICAL SCIENCES 

FOR JANUARY 1876. 



Art. I. — The Effect of Small Doses of Mercury in modifijing the num- 
ber of the Red Blood Corpuscles in Sijiohilis; A study of Blood-counting 
with the Hematim^tre. By E. L. Keyes, M D., Adjunct Professor of 
Surgery and Professor of Dermatology in the Bellevue Hospital Medical 
College, New York, etc. (With two wood-cuts.) 

The value of mercury in the treatment of syphilis is recognized quite 
generally in the profession, but the most varied views are held as to the 
best method of using the remedy. Some practitioners advocate the old 
method, a prompt, brilliant coarse to induce salivation, hoping, alas, 
vainly! to strangulate the disease.' Many, a majority indeed, believe in 
the value of numerous, interrupted, short treatments, not pushed to saliva- 
tion ; while others maintain that the best course to secure a patient from 
serious trouble, early or late in the disease, is to give mercury unremit- 
tingly during a long series of months. 

To this last class I have always belonged, and my observation, now 
extending over ten years, fortified by the larger and longer experience of my 
friend and partner. Prof. Van Buren, leads me to hold to my position still, 
until another course can be proved to be more beneficial to the patient, or 
this one can be shown to do him harm. 

The position is this, that syphilis is most surely controlled — most often 
cured, as far as any future evidence of its existence is concerned — by the 
unremitting use of small doses of mercury, continuously given during not 
less, and very often more than two years, the quantity being barely enough 
to keep down the symptoms and not enough to make the patient physi- 
cally conscious of taking any medicine at all; the drug being pushed if 
necessitated by symptoms, and iodide of potassium being used when re- 
quired. 

No. CXLL— Jan. 1876. 2 



18 Keyes, Mercury in the Treatment of Syphilis. [Jan. 

I believe it to be a rule, to which there are very few exceptions, that a 
patient in fair general health with syphilis treated in this manner from 
the period of his first eruption, and attending, meantime, to hygienic laws, 
will have but one general eruption (the first, and perhaps that will not be 
fully generalized), will have no serious lesion subsequently, and will be 
and continue to be in as good or better health after his treatment than 
before. To this rule, of course, there are exceptions, but they are not 
numerous. 

In reading a paper by Liegeois,' I was first apprised of the fact that 
small doses of sublimate, administered to healthy men or animals, caused 
them to increase in weight. Larger doses, of course, were followed by 
loss of weight, and, naturally, still larger ones were fatal. 

I came to accept this statement as a fact, without seeking to demon- 
strate it by personal experiment, because I had clinical proof in many of 
my syphilitic patients, whom I watched slowly gain in weight and strength, 
while under the prolonged use of minute doses of mercury. 

1 was familiar with the well-known results of the examinations of syphi- 
litic blood made by Ricord and Grassi, and with the wide-spread prejudice, 
partly due to these experiments, that mercury reduced the proportion of 
red blood corpuscles, while iodide of potassium increased it early in syphi- 
lis. Yet clinical experience with small doses of mercury spoke loudly 
against this view, and I could not honestly heed the purely scientific 
warning of Grassi. 

In 1874, in a very interesting article containing the tabulation of many 
careful experiments, Wilbouchewitch" arrived at the following conclusions 
concerning the blood in the early days of syphilis : — 

1. Small doses of mercury, when given to a syphilitic patient, increase 
the number of red blood corpuscles at first, and slightly diminish the num- 
ber of the white globules. 

2. The long-continued use of small doses of mercury gives the same re- 
sults which mercury in large doses yields in animals; namely, diminution 
of the red blood corpuscles, diarrhoea, etc. 

3. It is, consequently, important to know when to discontinue treatment, 
and this can only be determined by counting the blood corpuscles. 

4. It is necessary, in treating syphilis, to give mercury until the red 
corpuscles begin to diminish in number, then to cease in order to allow 
them to increase, to return to mercury when the number of red cells again 
diminishes under the influence of syphilis — and so on indefinitely. 

' Des Re.sultats cliniques et scientifiques obtenus avec les Injections sous-cuta- 
nees de sublime k petites doses dans I'etude de la Sjphilis : Gaz. des Hop., 88, p. 
347, 89, p. 350, 1869 — noticed by me in a Report on Syphilis, N. Y. Med. Gaz., 
Feb. 26, 1870, p. 150. 

2 De I'Influeuce des Preparations mercurielles sur la Richesse du Sang en Glo- 
bules rouges et en Globules blautis — Archives de Physiologie, 4 aud 5, 1874, p. 
508. 



18T6.] Keyes, Meiriiry in the Treatment of Syphilis. 10 

On reading this article attentively, it became clear to me liow M. Wil- 
bouchewitch, while counting the blood corpuscles of his patients conscien- 
tiously, might, by a faulty interpretation of liis facts, have arrived at the 
above conclusions. 

1st. All his patients, each with chancre, some with an early eruption, 
were treated in a hospital (Midi), taken away from their ordinary mode 
of life, and associated with sick people amid the depressing surroundings 
of hospital existence, with the sad picture of syphilitic eruptions, such as 
they saw around them, constantly on their minds as in prospect for them- 
selves. 

2d. Of the ten cases from which the conclusions of the paper were 
drawn, five received (each) a little over ^ gr. of corrosive sublimate four 
times a day from the commencement (4 centigrammes daily), the other five 
got I gr. of protiodide of mercury twice daily (10 centigrammes a day) — 
surely in neither case a very small dose. 

3d. The falling off in red corpuscles commenced at varying periods — 
after from 5 to 24 days of treatment, a mean for the ten cases of exactly 
eleven days — and yet the author does not seem even to suspect that, possi- 
bly, his patients are being over-dosed. 

4th. In five cases only is mention made of the weight of the patients. 
These lost, respectively, over 2^, 2^, 3i, 3i, 3^ pounds, and that in a very 
few days. It seems impossible that even a careless observer could have 
drawn any conclusion from a patient who lost d^\ pounds in 20 days of 
mercurial treatment in a hospital (Case III.), except thateither the hospital 
injured him or that his treatment was excessive, yet neither of these ideas 
seems to have occurred to M. Wilbouchewitch. It would have been extra- 
ordinary had there beeu an increase of red blood cells above the general 
standard in these cases. 

5th. In five of the ten cases tlie blood was counted again at periods 
varying from eight to nineteen days after the patient had left the hospital 
and discontinued treatment. lu each case the number of red cells had in- 
creased, and it is but fair to infer that the patients had also gained in weight 
under their improved hygienic surroundings — but upon this point the 
author is silent. 

It seems, therefore, that it is upon an erroneous interpretation of facts that 
Wilbouchewitch has built his theories and formulated his scientific laws 
for the treatment of syphilis. The above analysis of his facts seems to 
me to destroy the value of his premises and to make his conclusions 
worthless. 

Wilbouchewitch also killed a few rabbits with large doses of mercury. 

In the " Report of the Edinburgh Committee of the British Medical 
Association, by J. Hughes Bennett,'" there are fourteen carefully tabulated 

' Researches into the Action of Mercury, etc., on the Biliary Secretion, 2cl ed., 
London, 1874. 



20 Keyes, Mercury in the Treatment of Syi)hilis. [Jan. 

records of experiments made upon dogs, by giving them different forms of 
mercury in varied doses. The experiments were carried on solely with a 
view to determine the action of the substance employed upon the liver, yet, 
incidentally, a close study of the tables yields the following important 
information — of which, however, the Committee took no note. 

Corrosive sublimate, blue pill, or calomel was given, but whatever mer- 
curial was used, the dog invariably lost weight when a large dose of the 
mineral was administered, whether kept up for a short period (1| gr. sub- 
limate during 1 day, loss | pound) or for a long one (19|^ gr. sublimate 
during 13 days, loss 7^ pounds, p. 29). 

Absolutely, the only instances in the report where a gain in the weight 
of the dog is noted, are two. In both, comparatively small doses of 
corrosive sublimate were employed, from ^ gr. daily to ^ gr. twice a day — 
and a continuance of the latter large dose for more than 48 hours caused 
a loss of about 6 pounds in one case, while the same dog, suffering from 
an artificial fistula iu the abdomen, had increased in weight over three 
ounces in four days under the administration of \ gr. corrosive sublimate 
twice a day, and had held what he gained until the dose was increased 
(p. 51). The other animal (p. 49) took four grains of corrosive subli- 
mate in twelve days, and gained about the same amount. These are the 
only dogs of the series in which a gain in weight is noted, and they each 
had abdominal fistula. They alone took reasonably small doses of mer- 
cury. 

Upon the data set forth above I undertook to investigate the effect of 
mercury upon the blood. This paper is a record of the results obtained. 

The Hematimetre. — A special instrument is necessary in order even to 
approach accuracy in an estimation either of the quantity or number of 
cellular elements contained in a given volume of blood. Chemical methods, 
those yielding the often-quoted estimates of Andral and Gavarret, of Bec- 
querel and Rodier, those of Hittorf, Erlenmyer, Marchand, Nasse, Zimmer- 
mann, and others, can only be approximative. Grassi's method' was 
chemical like that of Andral, but deserves particular mention as being the 
first scientific effort (1844) to determine the effect of syphilis, and of the 
use of mercury and of iodide of potassium in this disease, upon the pro- 
portion of red corpuscles in the blood. 

All the methods of actually counting the blood cells which are found 
referred to by writers on this subject (those of Hirt, Lorange, Marfeis, 
Moleschott, Yierordt, Welcker, Mantegazza, etc.), whether they were for 
counting the red or the white cells, had the defect of not accurately estab- 
lishing the count for a given volume of blood. The dilution of the blood 

' Referred to by MacCarthay, Du Diagnostic et de rEuchaiuement des Symp- 
toines syphilitiques. These de Paris, 1844, and latlier fully in Ricord's Lei;ons sur 
le Chancre, 2d Ed., Paris, 1860, y. 18.5. 



1876.] 



Keyes, Mercury in the Treatment of Syphilis. 



21 



was known, and the superficies included in the count more or le.ss accurately 
estal)lished ; l)iit the thickness of the layer of blood counted was a more 
or loss variable Victor. Many of the attempts formerly made were under- 
taken to establish, approximately, the relative proportion between the 
white and red corpuscles rather than to determine the absolute number of 
red corpuscles contained in a given volume of blood. 

The first recorded instance of which I am aware wherein accuracy was 
aimed at in estimating the e.xact volume of blood counted, was that of 
Cramer,' and a cultic millimetre of blood was adopted as the unit of volume. 
The process was a rough one. 

In 1867, Potain made a positive step in advance in this direction by 
devising an ingenious set of instruments, requiring, however, considerable 
skill and care in their management, which allowed him, by the use of a 
special mathematical formula, to arrive at an easy estimate of the number 
of red corpuscles in a cubic millimetre, by counting a small portion of 
diluted blood. 



Fig. 1. 




Malassez' gave Potain's method to the world and wrote (and is still 
writing) extensively upon the subject of blood-counting. The instrument 



' Nederl., Laucet, 1855, referred to by Hayem Gaz. Hebd., May, 1875. 

2 Comptes Rendus de I'Academie dea Sciences, Dec. 1872 ; De la Numeration 
des Globules rouges du Sang, These de Paris, 1873; Noiivelle Methode de Nume- 
ration des Globules rouges et des Globules blancs du Sang, Archives de Physio- 
logie, 1874, 1. p. 291. 



22 



Keyes, Mercury in the Treatment of Syphilis. 



[Jan. 



described and used by Malassez is somewhat complicated, and not free from 
the accusation of possible inaccuracy. I shall not describe it, as a much 
more simple and exact apparatus exists. I refer to the hematimetre of 
Hayem and Nachet, recently described (with plates) by the former gentle- 
man.^ 

This is the instrument which I have used. 

Fig. 1, represents all its essential parts except the microscope. A few 
words will suffice to describe them. 

a, is a graduated glass pipette, each line on the tube marking off a 
capacity of 100 cubic millimetres, 5 D therefore indicates 500 cubic mm. 

b, is a smaller capillary pipette graduated to 2, 2h, and 5 cubic mm.; 
the operator takes the rubber tube c into his mouth to facilitate the 
entrance of blood into the pipette by suction. 

d, is a glass slide upon which is cemented a glass cell with a circular 
opening 1 centimetre in diameter, the depth of the cell Ijeing exactly i mm.; 
€, the covering glass to fit over the cell. A drop of fluid is represented in 
the cell. 

/, is a small glass cup to receive the blood and artificial serum for mix- 
ing. It fits into a brass stand g, to insure firmness ; h, is a glass rod with 
which to mix the fluids. 

The apparatus is completed by a microscope having a special eye-piece 
(No. 2 Nachet) containing a quadrilateral micrometer, Fig. 2. 

Fig. 2. 




The large square of the micrometer is further divided into sixteen smaller 
squares, while each smaller square contains a line drawn half way across 
it to facilitate the counting. 



' De la Numeration des Globules du Sang, Gaz. Hebd., May 7, 1875, p. 291. 



1876.] Keyes, Mercury in the Treatment of Syphilis. 23 

Manner of using the Instrument. — The ocular above described, being 
adjusted to a microscope, the draw-tube is so arranged that for a given 
objective (No. 2 Nachet is suitable) a side of the square micrometer in the 
eye-piece measures accurately ^ mm. upon a stage micrometer. The 
depth to which the draw-tube has been pushed in is then scratched upon 
the tube so as to be readily arranged in a moment, and the microscope is 
ready for use. 

I have always adopted as a standard of dilution 1 to 250, as this scatters 
the corpuscles sufficiently to make them easy to count. The actual pro- 
cess is as follows : — 

The pipette a, is filled to the mark 5 d, with the diluting fluid, which 
is at once emptied into the glass cup /. The pulp of the finger of the 
patient whose blood is to be tested should be deeply pierced with a glover's 
needle having a triangular cutting point. The blood should not be driven 
forward into the finger by pressure before the puncture. A string should 
not be tied around the finger. A round sharp needle should not be used. 
Repeated experiments, with needles and knives upon myself, which lack 
of space forbids my reproducing here, have proved to me that the above 
suggestions must be heeded in order to be certain of always obtaining 
uniform specimens of capillary blood. The triangular cutting needle 
does away with Hayem's objections to puncture,' and is a less formidable 
instrument than the knife in the eyes of the patient. 

After piercing the pulp of the finger quick firm pressure down the finger 
will force out a large drop from the puncture. This must be sucked into 
the capillary pipette without delay, lest it coagulate. When the pipette 
is full to the mark 2, its point should be rapidly wiped clean of any blood 
adhering on the outside, and the contents at once blown into the artificial 
serum in the cup f. A little suction back and forth clears the tube of any 
blood corpuscles which may have adhered to the glass within. Both tubes 
should be carefully washed before being put away. 

The mixture should now be thoroughly agitated with the glass rod, 
and before it has time to settle, a drop is placed in the middle of the cell 
on the slide d, care being taken that the drop is not large enough to touch 
any part of the circumference of the cell (Fig. 1, d). The covering glass 
e, should be immediately placed upon the cell. Should the drop be too 
large, so that, when the thin glass is adjusted, it spreads out enough to 
touch the circumference of the cell and to be partly sucked up beneath 
the covering glass and top of the cell, the latter must be wiped and a new 
drop placed within it. Finally a small drop of water or saliva is applied 
to the edge of the covering glass, under which it circulates around the top 
of the cell, serving to hold the cover in place and prevent the evaporation 
of any part of the drop within. 

1 Loc. cit., p. 294. 



24 Keyes, Mercury in the Treatment of Syphilis. [Jan. 

The slide thus prepared is placed under the microscope. In a few 
moments the counting may begin, the blood corpuscles will have all settled 
to the bottom of the cell, and a picture similar to that shown in Fig. 2 
will be seen on looking through the microscope. The counting should 
not commence until all the corpuscles are upon the same plane and can 
all be focused together. It is better to count each of the sixteen squares 
and write down its nusiber separately, so that in counting the square 
beneath it, should there be any doubt a!)out counting a given corpuscle 
lying upon the line, a glance at the number recorded for the square above 
may remove all doubt. Many corpuscles will be found lying upon the 
outside lines bounding the large square. I have adopted the rule of 
rejecting all those lying upon the upper and right-hand outside lines (of 
tlie large square) and counting all those lying upon the lower and left- 
hand outside lines. 

After having thus obtained the number of red corpuscles situated within 
the large square, it becomes easy by a simple equation to find the number 
in a cubic millimetre. A single count, however, exposes to sources of error, 
and in order to approach more nearly to exactness, I have uniformly 
counted the number contained in the large square in five different portions 
of the field (sometimes ten), and have taken a mean of the whole number 
of counts as the standard. 

The computation is as follows: The glass cell on the slide is i mm. 
deep. The eye-piece micrometer marks off i mm. square, therefore, the 
count of red corpuscles (or white as the case may be) must indicate the 
number contained (in the dilution used) in | mm. cube. But i mm. cube 
is 1-1 25th of a cubic mm., therefore, the number counted must be multi- 
plied by 125; and the blood was diluted by adding 250 parts of fluid 
to 1 of blood (2 cubic mm. to 500 cubic mm.), therefore the product 
above obtained must be again multi})lied by 251 to get the number of cor- 
puscles in a cubic mm. of pure blood. Instead of multiplying twice, a 
single multiplication by the product of 125 X 251, 31375, will give the 
same result. 

Letting x=z the mean of 5 counts; the equation then is simply: 
The number of red corpuscles in a cubic mm. of blood ;= ar X 31375. 

Fluid used to dilute blood for coinHing. — I experienced great difiQculty 
in obtaining a good fluid for diluting blood, which time would not alter. 
All of those proposed are serviceable while fresh, but none of them will 
keep when a pipette is dipped into it daily. Bacteria, when present even 
in small numbers, make the count very uncertain, because the motion of 
the little rods causes the corpuscles to move about the field and to run 
together into groups, and as each corpuscle in the large square counts 
for 31,375 in the final result, it becomes at once apparent that anything 
making it difficult to avoid counting a corpuscle twice or tending to dis- 
tribute them unevenly is disastrous to accuracy. 



1876. J Keyes, Mercury in tlie Treatment of Syphilis. 25 

Round and oval-ceiled cryptogaraic growths in a diluting fluid are also 
objectionable, since some of their cells are apt to be counted as blood cor- 
puscles and vice versa. The artificial serum of Malassez (1 vol. of solution 
of gum acacia sp. gr. 1020, and 3 vols, .solution of equal parts of sulphate 
of soda and chloride of sodium of same density) is open to this objection; 
and, besides this, has the defects of distorting the corpuscles in shape and 
disolving them after a few hours. 

My friend Dr. L. A. Stimson, to whom I am indebted for much valua- 
ble assistance in experimenting to obtain a proper fluid, brought me, in 
the month of May, from Paris, an ounce of Schultze's iodized amniotic 
liquid of the cow. This makes a homogeneous mixture with blood, but 
contracts the red corpuscle somewhat, and after the bottle has been dipped 
into a few times with the pipette, my ounce, at least, was swarming with 
bacteria. The same criticism applies to the fluid of ascites, and the clear 
serum from a hydrocele of the tunica vaginalis. Iodine, carbolic acid 
(pure or impure), salicylic acid, iodate of calcium,- carbonic acid, sulphur- 
ous acid — none of these, unless added in a strength destructive to the blood 
corpuscle, is able to prevent the rapid development of bacteria in either 
of the two fluids above mentioned. 

In searching for a good fluid, Dr. Stimson and myself tried a variety 
of saline solutions, but failed to find perfection in any of them. Finally it 
occurred to me that healthy urine containing blood, often shows tlie blood 
corpuscles perfectly preserved in size and shape on the day following that 
on which the specimen was voided. Knowing that a proper fluid must have 
a specific gravity of about 1020 in order not to distort or dissolve^ the 
corpuscles, I experimented with healthy urine of that sp. gr. The speci- 
men I used was neutral, sometimes very faintly alkaline (phosphatic, not 
amraoniacal), and answered admirably. But urine will not keep long even 
when filtered, especially if it is contaminated by having a pipette dipped 
into it. Bacteria will appear in it very promptly, and as it is inconvenient 
to get a fresh specimen of urine to use each day, I undertook to prepare 
a permanent urinary fluid. This was finally accomplished, and I give the 
result, omitting the steps by which it was reached. 

Take urine, neutral, slightly phosphatic, easily obtainable after eating, 
about 1020 sp. gr., and make of it a saturated solution with borax. 
Clouds of earthy phosphates are thrown down. Filtration yields a clear, 
alkaline fluid sp. gr. about 1030. Add one-half volume of water, or 
enough to reduce the sp. gr. to 1020, and the fluid is ready for use. 

This fluid retains its brilliancy for a long time,^ although daily contami- 

' Too light a fluid, water for instance, dissolves the corpuscles so quickly that 
not one of them can be found on putting the mixture prepared with it, imme- 
diatelj under the microscope. Too heavy fluids distort the corpuscles and cause 
them to collect into heaps. 

' Mould appeared upon it after two mouths. 



26 Keyes, Mercury in the Treatment of Syphilis. [Jan. 

nated by the pipette ; no bacteria or confervoid growths appear. It makes 
a homogeneous mixture with blood, and preserves the color of the corpus- 
cles. The latter become perfectly spherical, are slightly, but uniformly 
contracted (measuring 0.0006 mm.). They are perfectly preserved for a 
number of hours, after which some of them begin to dissolve. 

The above is a good fluid, and has no poisonous properties. The 
following is very much better, but the corrosive sublimate may make it 
objectionable to some.' 

Take of urine, neutral or slightly alkaline, sp. gr. 1020, a sufficient 
quantity, filtered. Add gr. v of corrosive sublimate in powder for each 
ounce of urine. This will throw down dense clouds of amorphous urates, 
so fine that ordinary filter paper will not remove them. After standing, 
the urates deposit, and the clear fluid above may be easily decanted. 
Reduce with water to sp. gr. 1020. 

The result is a limpid, sparkling, acid fluid which remains clear no 
matter how often contaminated with the pipette, and does not seem to 
allow of the growth of any form of vegetation. It makes a perfect mix- 
ture with blood. It bleaches the red corpuscles quickly, and very slightly, 
but uniformly, increases their size. They retain, however, their flattened, 
bi-concave, disk-like shape, and do not become dissolved after standing 
more than twenty-four hours — beyond which time no test was made. 

Estimation of the accuracy of the Eeraatimetre. — Theoretically the 
method of enumerating the blood corpuscles with the instrument of Hayem 
and Nachet is absolutely accurate ; practically it is not so. This is 
largely due to the minuteness and infinitely vast number of the objects 
counted. It would be folly to try to calculate the number of red cor- 
puscles in the human body, for when obtained, the figures would give no 
more idea to the ordinary mind of what the number really is, than would 
the word infinite. 

For example — to reduce the whole matter to figures which can be 
easily understood — the population of the entire earth is estimated at con- 
siderably under 1,500,000,000. The hematimetre shows that one cubic 
mm. of pure blood of a male adult in good health, holds on an average 
5,000,000 red blood corpuscles. But a cubic millimetre does not furnish 
a very accurate idea to the mind. A centimeter is better, it is of appre- 
ciable size, something over the third of an inch (exactly .39371 inch). 
A cubic centimeter is equal to 1000 cubic millimetres, and, therefore, con- 
tains 5,000,000,000 red blood corpuscles — a number of distinct red cells 
(not to count the white corpuscles) in each cubic third of an inch of blood, 
more than three times greater than the population of our entire globe. 

This vast number of cells is probably undergoing daily and hourly 

' It is a strange coincidence that I should have found mercury the best pre- 
servative for blood corpuscles. 



1870.] Kf.yes, Mercury in the Treatment of Sy|)liilis. 27 

variation to a slight extent. '\Vill)oiiche\vitoh noticed a very marked in- 
crease after meals. I endeavoured to avoid this source of error by counting 
my patients between the hours of 9 and 12 in the morning. In my own 
case there was a marked diminution after being up most of the night with 
a patient — a loss fully recovered from on the next day. In counting the 
same drop of diluted blood, it is rare for any two counts to be exactly 
alike, and for this reason I have always taken the mean of 5, often 10, 
counts, to approach more nearly to accuracy. This seems more necessary 
when we consider that each separate corpuscle counts for 31,375 in the 
final result — but yet, after all, 30,000 is a small matter when compared 
with the infinite number of these little cells. I have found it prudent also 
not to count very near the edges of the drop on the slide — where the cor- 
puscles are apt to collect together unevenly. 

In the same drop on different counts carefully made (mean counts of 5, 
not single counts), I have sometimes found a difference in the final result 
of as much as 200,000 to the cubic mm. Therefore, I cannot look upon 
this method, although followed out with conscientious care, as being abso- 
lutely accurate, nor should I consider a few counts, taken alone, of any 
value whatsoever. But relatively, I believe it to be very reliable, and if, 
in a great number of counts in different cases, the testimony of the figures 
should be largely in one direction, and the counting had been conscien- 
tiously performed, I should consider their evidence unimpeachable. 

Of course for accurateness of results, to compare with those of another 
observer, the glass cells must be absolutely equal in depth. That this is 
generally so I doubt not — but it is not always so. There is a difference 
in depth of about -^^ mm. between ray cell and one in possession of Dr. 
Stimson. There is a uniform difference of about 10 per cent, in the count 
of the same blood in the different cells. This is undoubtedly due to the 
fact that the depth of the cells is measured (they are ground after being 
cemented) with a sharp-pointed instrument, which might readily make an 
error of nearly ^^ mm. on account of inequalities in the surface of the glass. 

Each cell, however, is absolutely accurate in itself, and the relative 
results obtained by it are (relatively) accurate; therefore, any series of 
observations made with one and the same cell, possesses positive value, 
whether the actual numbers accord with the results of observers using 
other cells or not. 

All the counts contained in my tables were made with a single cell, 
whether counted by Dr. Stimson or myself. Absence of error was still 
further secured by getting Dr. Stimson to make many of the counts for me, 
he knowing neither the patient nor his previous count. In the experi- 
ment upon myself, where I took mercury for a fortnight. Dr. Stimson 
made all the counts of my blood, ignorant of what experiment I was the 
subject. 

I have certainly taken every honest scientific precaution in my experi- 
ments, always counting (or having counted for me) the blood as soon as 



28 Keyes, Mercury in the Treatment of Syphilis. [Jan. 

it was drawn, and recording the figures in a book, one after another, with- 
out order, attached to the name of the patient and referring to his case in 
ray note book, and entirely disconnected from any previous count. I 
entered upon the investigation as a searcher for truth, and came out con- 
vinced but astonished. After collecting together the scattered counts and 
arranging them into tables, I was infinitely surprised at the uniformily 
of the result; not at the result, for, candidly, that I expected, but at its 
wonderful uniformity. Had I manufactured the figures myself I could not 
have done more to sustain the statement: that mercury, in small doses long 
continued in syphilis, increases the numl>er of red corpuscles in the blood, 
and maintains them at a high standard in a majority of all cases. 

Tabulated experiments, ivith remarks. — I have carefully counted the 
blood 101 times (5 to 10 counts each), not including a great number of 
counts to settle side issues of various kinds. A record of the blood of 27 
individuals is contained in the following tables, of which 6 were apparently 
sound, 20 syphilitic. My first recorded count was on June 5, 1875 ; my 
last for this article, Oct. 26, 1875. Most of the patients were in affluent 
circumstances, many of them spending the greater part of the summer out 
of town ; 3 hospital cases only were counted for comparison. The cir- 
cumstances, therefore, are favourable for rather high counts. 

The cases will be grouped into tables and considered as follows : — 

I. Average of red blood corpuscles in 1 cubic mm. of blood of the 
healthy adult male. 

II. Effect of small doses of mercury upon the blood early in sypJiilis. 

III. Effect of the long-continued use of small doses of mercury upon 
the blood in syphilis. 

IV. Effect of mercury in excess upon the blood in syphilis. 

V. Effect of mercury combined with the iodides upon the blood in 
syphilis. 

VI. Effect of mercury, in hospital, upon the blood in syphilis. 

VII. Effect of small doses of mercury upon the blood in individuals 
not sypliilitic. 

No special attention has been given in these experiments to the white 
blood corpuscles, or to the effect of iodide of potassium alone ; both very 
valuable subjects for investigation. In some cases of late syphilis counted, 
but not included in this report, the iodide of potassium, used alone, seemed 
very active in its power of increasing the number of the red blood cells. 
The counts taken of women are not included in the report, as the number 
of cells they possess seems to be naturally somewhat lower than that of 
men, and my object has been to establish a just comparison between the 
results obtained from healthy men and adult males with syphilis who had 
been for a longer or shorter period under mild mercurial treatment. None 
of the cases (except the hospital ones) were selected, but all were taken 
as they came along, at least such as could be induced to allow themselves 
to be counted, and such as the hurry of morning office hours gave time to 
count. I have avoided multiplicity of figures and of details as much as 



1S76.] Keyes, Mercury in the Treatment of Syphilis. 29 

possible in the following' tables. Figures are perplexing to the eye and 
wearisome to the mind. 

I. Average of red blood corpuscles in 1 cubic mm. of blood of the 
healthy adult male. — To obtain a healthy standard for comparison, I made, 
with the help of Dr. Stimson, 33 examinations of 5 or more counts each. 
The conditions were most favourable for a high standard. The time was 
summer, the individuals all in flourishing health. Of the five whose blood 
was counted, Dr. Stimson was just from Europe, in the full flush of health, 
and during the period of counting, passed most of his time in the country. 
For myself, I was in excellent health, and during July was in the country 
for four days and five nights of each week, in full relaxation of mind and 
body, doing no work harder than fishing. Of the other three individuals 
counted, one was a full-blooded gentleman living in the country, two 
others, young physicians, one in town, one in the country. Two out of 
the five are six feet tall, and weigh about 200 pounds each ; a condition 
seemingly favourable to a high count. 

Table I. 

No of red corpusolea Remarks. 

iu 1 cubic min. 

1^ „ . , , j" Counts extended from ,Tnne 5th to September 15th. 

,i\ ' ' > 5,OGS,793. \ Taken at all liours of the day, before and after 
raceof 14 counts, ) ' i * * 

° ' ( meals, to get an average. 

Dr. Keyes, ave- I 4 q-i r qia / Inclusive, from June 5th to July 22d ; also taken 

rage of 14 counts, j ' ' '1 iuditlerently at all hours of the day. 

Dr. , 3 counts, 5,045,063. Lives iu country ; fat, young, well. 

Dr. , 1 count, 4,706,250. Not fat, but in good health ; living in town. 

Mr. , 1 count, 5,697,700. Large, fat, beyond middle age ; healthy ; lives in 

country. 

Average 33 counts, 4,990,550 

The above table is .derived from exceptionally good sources. As for 
the number of blood corpuscles, I believe that each man is a standard to 
himself ; but it was necessary to get a general average of good health to 
use as a standard of general comparison for patients not well, and those 
under the influence of mercury for a long time when first counted, as their 
own natural standard in health could not be known. 

The above estimate, of nearly 5,000,000 blood corpuscles for the cubic 
ram., I believe to be a high average for Americans in the neighbourhood 
of New York during the summer and autumn. 

To compare the above result with that obtained by other investigators, 
Hayem' places the mean at about 5,000,000, more or less, for the blood 
of the finger of the healthy adult male. Yierordt established as a mean 
for his own blood something over 5,000,000. Welcker estimated it at 
4,600,000 ; Cramer at 4,726,000. Malassez gives the lowest, placing the 
number at something less than 4,500,000 ; but he is not very definite upon 
the subject of healthy average, being more interested in his writings in a 
description of the instrument and in considerations of diseased blood. 

In the most extreme cases of anseraia (excepting only two cases) Hayem 

' Loc. cit., p. 295. 



30 Keyes, Mercury in the Treatment of Syphilis. [Jan 

never counted less than 3,000,000. In this respect my experience has 
been similar to his. 

II. Effect of small doses of mercury upon the blood early in syphilis. 
— The following five cases all had early syphilis. The chancre was seen 
and treated upon all except patient e, whose primary lesion occurred four 
months before commencing treatment. The protiodide of mercury in 
granules, gr. i each, was used in every case (except e), and, as every man's 
capacity for mercury varies, each patient was ordered to commence with 
one granule after each meal, and to increase by one granule each day (not 
each dose) on every fourth day, until there was some evidence of irritation 
produced by the mercury, when the dose was to be immediately reduced to 
one-half, and there held until further notice. lu the table a double line 
- indicates that below that point mercury was taken. 

Table II. 

Patient a. 

No. of red corpuscles Remarks. 

ia 1 cubic mm. 

June 21, 3,457,525. Chancre ami indurated glands. Patient thin, delicate ; goes 
to country for summer. Tonics, etc. ; no mercury. 

July 2, 4,564,062. Appetite good ; mind easy; gain in weight and strength. 

July 20, 4,516,900. Health fair ; continue tonics and cod-liver oil. 

Sept. 4, 5,283,550. Fat and well; chancre healed, indurated epitrochlear gland, 
— erythema of fauces ; commence mercury. 

Sept. 18, 5,327,475. Three and up to six granules ; average gr.j protiodide daily ; 
slight mucous patches on lips, tongue, and throat; no 
eruption; appetite excellent. 

Chancre healing; commencing roseola ; no fever; epitroch- 
lear and post-cervical glands indurated ; commence mer- 
cury. 

Reached six granules ten days ago, since then three daily ; 
roseola. , 

Slight relapse of roseola, some pains in joints ; takes five 
granules daily. 

Roseola and pains gone ; mucous patches on tonsils and 
anus; patient fat, in excellent healtli and spirits; has 
recently been taking four granules a day. 

Health good; lives in country ; infecting chancre now ten 

days old ; to commence mercury. 
Five granules a day with a little iron. 
Has gained six pounds in two weeks by change of residence 

in the country ; takes six granules. 
Has come to town to work ; lost weight ; erythema of fauces ; 

faint mucous patches. 
Mind depressed, appetite poor; osteocopic pains ; plentiful 

mucous patches ; no eruption, fear of which keeps him 

terribly anxious ; looks well ; takes six granules daily. 

Chancre eight weeks ago ; mercury for nineteen days ; 
eight granules were reached; now four are taken; mu- 
cous patches ; has had faint roseola. 

Chancre four months back; abundant mucous patches and 
post-cervical glands ; no eruption ; probably has been 
taking mercury, but is not certain ; to take three grains 
of blue pill daily with chlorate of potasb. 
Oct. 2, 5,578,875. Mucous patches nearly well. 





Patient b. 


Aug. 


20, 
,13, 


4,586,025. 


Sept. 


4,636,450. 


Oct. 


2, 


4,863,125. 


Oct. 


26, 


5,396,500. 




Pat 


ient c. 


Aug. 


28, 

3, 

22, 


4,863,125. 


Sept. 
Sept. 


5,200,975. 
6,168,325. 


Oct. 


5, 


5,606,125. 


Oct. 


26, 


5,208,250. 




Patient d. 


Sept. 


7, 


5,127,665. 




Pati 


lent e. 


Sept. 


20, 


5,484,350. 



1876.] Keyes, Mercury in llie Treatment of Syphilis. 31 

These cases do not call for inuch comment : a improved greatly under 
his tonics and hygiene, and still further under a mild mercurial; b gained 
over 800,000 in his count while taking a mild mercurial continuously for 
ten weeks ; c, under splendid hygienic surroundings, after taking mercury 
for twenty-five days, showed an increase in his count of over 1,300,000, 
corresponding to the clinical expression of improvement denoted by six 
pounds gain in weight in two weeks ; but afterwards, under the depressing 
influence of poorer hygiene, hard work, and the anxiety caused by the fear 
of a general eruption, he lost his extra weight, and the gain in corpuscles 
fell off to only a little over 300,000 above his first count. This man was 
taking mercury continuously for two months, and, according to Wilbouche- 
witch, should have fallen off largely from his first count. 

a, b, c were first counted before they had taken any treatment — one 
was delicate, the other two very healthy, yet they all marked below 
5,000,000, the healthy standard. Notwithstanding this they all reached 
above 5,000,000, protected by hygiene and mercury from the depressing 
influence of advancing syphilis. 

d and e were not counted until they had taken mercury for some time, 
and both of them when counted reached above the healthy standard, 

III. Effect of the long-continued use of small doses of mercury upon 
the blood in syphilis. — From the following table I have felt obliged to 
exclude all patients who had taken any of the iodides, making of these 
latter a special group. I have, therefore, only three patients to offer as 
examples of the harralessness — or rather the advantage — of the long-con- 
tinued use of small doses of mercury alone in syphilis. 

Table III. 

Patient/. 

No. of red corpuscles Remarks. 

in 1 cubic mm. 

June 7, 5,333,750. Chancre July, 1874. Has taken average of 1^ gr. protiodide 
of mercury daily for eleven months ; has occasional mu- 
cous patch. 

Oct. 22, 5,220,800. Continued above dose until six weeks ago ; since then has 
taken nothing. 
Patient g. 

June 11, 5,647,500. Chancre in December, 1874. For six months has averaged 
1^ gr. protiodide of mercury daily ; syphilitic rheumatism 
and mucous patiihes. 

Oct. 8, 4,699,975. Continued mercury until three weeks ago, when he was 
thrown from a carriage. He is just out of bed from his 
injuries, and has lost seven pounds in weight. 
Patient h. 

Oct. 4, 5,020,000. Chancre eighteen months ago ; mercury ever since ; average 
gr. j protiodide daily ; latterly f gr. daily. 

Oct. 26, 5,208,250. Continues at same dose; looks and feels well ; small ele- 
vated papular patch on leg. 

To crystallize out the facts from the above cases, it may be added : 
None were large men ; none were naturally robust ; one was lymphatic, 
and not very strong; one belonged to a phthisical family; one had only 



33 Keyes, Mercury in the Treatment of Syphilis. [Jan. 

a short time before recovered from prolonged sickness with an angular 
curvature of the spine. Yet all, after prolonged use of small doses of 
mercury for respectively eleven, six, and eighteen months, showed a'blood 
count above the healthy average, and, clinically, were in excellent health ; 
farther, e lost 100,000 after ceasing his mercury for six weeks ; g lost 
1,000,000 and T pounds weight from accidental causes, during the period 
of loss taking no mercury ; h, having no drawbacks, maintained his 
average. 

IV. Effect of mercury in excess upon the blood in syphilis.^ — The 
patient who furnishes the following table lived in the country, visiting me 
in consultation with his physician. He was a large man, fairly nourished, 
with a late syphilitic lesion (ten years from chancre) threatening an im- 
portant function. During his treatment an effort was made to produce 
mild salivation — the effect of which was, on the whole, somewhat beneficial. 
He took a mixed treatment. 

Table IY. 

Patient i. 

No. of red corpuscles Remarks. 

in 1 cubic mm. 

•luue 9, 4,027,818. For some time past has taken gr. xl of iodide of potassium 
t. i. d., and ,:^S3 inunction twice daily of 20 per ct. oleate. 

June 20, 4,391,500. Inunction of 3is.s of oleate daily, and gr. ij iodide, t. i. d. 
Manifest improvement in health, appetite, and the func- 
tion threatened ; no iodism or ptyalism ; ordered to push 

July 8, 5,333,750. inunction; add ^'^ gr. of biniodide of mercury to internal 
dose of .^j of iodide of potassium three time a day. 

Aug. 28, 4,398,775. One mouth ago diarrhoea and slight ptyalism came on and 
lasted till one week ago. Patient was greatly depressed 
at the time ; now feels better ; takes gr. -jV biniodide of 
mercury, and gr. xlv iodide of potassium, t. i. d. ; no 
inunction. 

Had it been possible to see this patient when salivated and count his 
blood then, instead of one week after his recovery, I cannot doubt, that 
his count would have been below 4,000,000. As it was he lost about 
1,000,000 by the excessive use of mercury. 

V. Effect of mercury combined ivifh iodides upon the blood in 
syphilis. — In this list, which naturally furnished the largest number of 
patients, it would be fair to expect frequent exceptions to the rule that 
mercury increases the number of the red corpuscles in syphilis, because so 
many of those patients who need prolonged treatment late in the disease, 
become more or less cachectic and broken in general health. I have been, 
however, surprised at the good showing these patients have made. Only 
2 of the 9 cases (j and r) averaged, on the whole number of counts, below 
5,000,000, the normal standard, and this among patients with old syphilis 
collected at random. 

' Patient s. Table VI., is another example of excess in mercury. 



July 


8, 


4,190,150. 


July 

Aug. 


23, 
20, 


4,258,165. 
4,307,344. 


Sept. 


8, 


3,934,425. 


Sept. 


23, 


3,733,225. 




Pa 


itient k. 


June 


10, 


4,944,700. 


July 


1(5, 


5,647,500. 


Sept. 


4, 


4,549,375. 



1876.] Keyes, Mercury in the Treatment of Syphilis. 33 

Table V. 

Patient j. 

No. of reJ corpuscles Kbmakks. 

ia 1 oiibic lura. 

June 9, 3,478,078. Lynipliatio, pallid, cachet-tic. Chancre three year.s ago ; 
ecthyma on legs ; papulo-siiuamous eruptions on scrotum. 
Has been taking a niiM mixed treatment of late. 

Eruption better ; has been taking gr. ,'2 biniodide of mer- 
cury and gr. iv iodide of potassium, t. i. d. 

Eruption nearly well ; has continued biniodide at j^t grain. 

Eruption well ; iodic acne. Has taken gr. ^'j biuiode and 
gr. X iodide of sodium. 

Constipation ; appetite poor; intense pain in anus at stool. 
I find lissure of anus and divulse the same. 

Fissure well ; general condition gradually bettering : takes 
gr. y'j biniodide of mercury, and gr. x iodide of potas- 
sium, t. i. d. 

Chancre ten montlis ago. Has taken mercury ever since, 
and lately some iodide. Is over-worked — run down ; has 
ulcerated throat ; is taking gr. -^^. bichloride of mercury. 
In country since last visit. Feels and looks better. Con- 
tinue mercury, adding gr. v iodide of potassium, t. 1. d. 
Iodide disagreed. Patient got an attack of diarrhoea with 
bloody passages, and stopped everything for a time. Is 
now taking gr. | protiodide of mercury daily. 
Patient I. 

June 22, 4,894,500. Tall and thin, not ansemic ; lost 25 pounds during past few 
years since he became syphilitic. Has been under mixed 
treatment ; lias large painful node. Has taken gr. xv 
potass, iod. t. i. d., but no mercury for four mouths past. 
Is gaining in weight. To take gr. v more of the iodide of 
potassium and r,'f gr. bichloride of mercury at a dose. 

June 29, 5,183,150. Is now witliin fifteen pounds of full weight Node less 
tender. 
Patient m. 

July 10, 4,473,075. Recently taking Donovan's solution. Chancre and erup- 
tions four and a half years ago. Six months of mixed 
treatment a year ago. Papulo-squamous patches and 
ulcers on scrotum. 

July 24, 4,392,500. Ulcers liave healed under gr. ^V biniodide of mercury, and 
gr. V iodide of potassium, t. i. d. 

Aug. 21, 5,020,000. Small ulcerated gumma of penis. Health excellent. Has 
been taking gr. Jj biniodide of mercury, gr. vijss iodide 
of potassium, t. i. d. 

Oct. 10, 6,193,425. Health splendid. Ulcer of penis well. Has been taking 
same medicines at doses of gr. jV-gr. x. Is five pounds 
heavier than full weight in ordinary health. 

Patient n. 
July 31, 5,195,700. Chancre three and a half years ago ; mercury ever since, 
with intervals of rest, recently. One small scaly patch 
on lower extremity. Patient desires to keep under treat- 
ment, as bis wife is pregnant with her first child. Takes 
gr. j\ biniodide of mercury, gr. iv iodide of potassium, 
t. i. d. 

, Has taken recently gr. l protiodide of mercury, t. i. d., and 
a little inunction of 5 per cent, oleate. 

. Just returned from the country in excellent condition. 
Takes gr. 1? protiodide of mercury daily. 

-Jan. 1876. 3 



Aug. 


20, 


5,020,000. 


Oct. 


7, 


6,092,925 




No. 


CXLL- 



34 Keyes, Mercury in the Treatment of Syphilis. [Jan. 

Patient o. 

JTo. of red corpuscles Eemarks. 

in 1 cubic mm. 

Aug. 20, 4,6'12,125. Syphilis several years' standing. Has taken a vast amount 
of iodides for syphilitic hemiplegia, mania, etc. Physical 
condition and appetite at present fair; has been taking 
gr. 3^^ of the biniodide of mercury, and gr. xxvij of the 
iodide of sodium, t. i. d. 

Oct. 4, 5,547,500. Has continued medicine steadily, improving in physical 
appearance. 
Patient p. 

Aug. 27, 6,444,515. In magnificent physical condition. Has taken mercury 
continuously for nearly three years, and continues to take 
it until his wife, who is pregnant with her tirst child, 
shall have been delivered. Is taking gr. v iodide of 
potassium, gr. yV biniodide of mercury, t. i. d. 

Sept. 17, 6,226,350. Has reduced iodide of potassium to 2V grains at a dose. 
Patient q. 

Sept. 22, 4,712,525. Large man, not anaemic. Chancre twelve years ago; no 
treatment for many years ; threatening of carious disease 
of bones of the nose and of paraplegia. To take mixed 
treatment of biniodide of mercury gr. ^^, iodide of potas- 
sium gr. vijss. 

Oct. 22, 5,400,0C'O. Improvement undoubted, especially of nose. 
Patient r. 

Sept. 22, 4,888,125. Old syphilis; general condition fair; persistent mild 
tuberculo-ulcerative lesion. Has been taking inunctions, 
with gr. yij biniodide of mercury and gr. v iodide of 
potassium, t. i. d. 

Sept. 28, 4,555,650. For one week has taken gr. xx iodide of potassium, and 
gr. ^^ bichloride of mercury, t. i. d. Eruptions worse. 

Xot considering any effect the iodides might have had, it will be noticed 
in these 9 cases, that T of them, when first counted, ranged below the 
normal standard of 5,000,000. That it was not the mercury which pro- 
duced this effect must be evident upon a careful perusal of the table. 

Patients J, k, I, m, o, r, were suffering from a continuation of symptoms 
of syphilis which treatment had not been able to remove, were more or 
less blighted by the disease. Patient q belonged to the same class, but 
had taken no mercury for nearly twelve years, and indeed, gained over 
600,000 in bis count by taking mercury for a month. 

The two patients who counted high were in perfect health, and both 
were continuing treatment simply from fear that, if they did not, some 
trouble might arise which would affect their pregnant wives and involve 
their children. One had a small scaly patch, the other absolutely nothing 
as an evidence of syphilis ; and patient p made the best count I ever ob- 
tained from any one, and had been taking mercury continuously for three 
years. The other patient reached over 6,000,000 after taking mercury 
almost uninterruptedly for three and a half years. 

Patients m, p, and even q, therefore, speak loudly in favour of the jiro- 
longed use of mercury. 

Patients j and r were severe, inveterate cases of disease, and poor 
specimens of the effect of treatment clinically, as well as microscopically. 



1876.] Keves, Meiviiry ill tlie Treatmciit of Syi)liilis. 35 

L' counted low at first, l)ccause pulled down by overwork. He reached 
over 5-i million.s at one time, and fell attain after diarrhcjea with Ijloody 
stools. 

I reached over 5,000,000 on gaining back a few pounds he had lost. 

m, depressed at first under a new outburst of disease, reached above 
6,000,000 by three months of mercurial treatment. 

o touched 5,500,000 while under observation. 

In short every patient of the nine had a general average above 5,000,000, 
except J and r. 

VI. Effect of mercury, in hospital, upon the blood in syphilis. — The 
l)lood of the following patients was counted to make a short study of the 
dilTerence between hospital and private patients. Three cases were selected 
in the Charity Hospital: one salivated, just admitted ; one an old case, in 
the hospital for two years ; one, a new case, with chancre just getting well 
when admitted. 

Table VI. 

Patient s. 

No. of red corpuscles Rbm.\rk8. 

ia 1 cubic ram. 

.Imie 13, 3,990,900. Salivated for fifteen days, ten of whicli in hospital. 
.Inne 20, 3,335,lt)2. Eats Imt little; salivation improving. 
June 27, 4,516,900. Salivation nearly well , eating well. 

Patient t. 
June 13, 3,081,025. Chancre five years ago ; rupia and nlceratious. Has been 

two years in hospital ; 3'j iodide of potassium, t. i. d., 

lately ; no mercury for six months. 
.June 20, 3,670,875. Has taken J^ gr. biniodide of mercury, and gr. xv iodide of 

potassium for a week. 
June 27, 3,592,333. Very positive improvement in ulcers ; same treatment. 

Patient n. 

June 13, 4,612,125. Young man; chancre two months ago; ten days in hospi- 
tal ; roseola ; no treatment as yet. 

June 20, 4,216,800. Has taken \ gr. protiodide of mercury, t. i. d.. for a week; 
roseola disappearing ; suppurative peri-adeiiitis threaten- 
ing in the groin. 

June 27, 4,551,888. Same treatment ; roseola gone ; suppuration averted in the 
groin. 

This table tells its own story : 

s entered salivated. His count increased after he began to eat. 

t debilitated by disease and hospitalism, showed a wretched count. 
His improvement under observation, I think, was largely due to the greater 
quantity of good air he got by going out of doors in the pleasant June 
weather; yet I certainly believe the mercury helped him. 

u, if counted daily, might for a time have furnished figures like those 
given by Wilbouchewitch, yet possibly better, in spite of his threatening 
bubo, because his dose of mercury was so small. 

VII. Effect of small doses of mercury upon the blood of individuals 
not syphilitic. — The material for this table was derived from two sources. 



36 Keyes, Mercury in the Treatment of Syphilis. [Jan. 

Patient v, a young man, badly frightened by an ulcer on the penis the 
nature of which, when first seen, could not be positively pronounced upon, 
insisted, for his own peace of mind, upon being treated until the time for 
the eruptions had passed. He was, therefore, by his own will and con- 
sent, put upon mercury, and made the subject of observation. He turned 
out to have no syphilis, much to his own and my satisfaction. 
I made myself the subject of experiment to fill the table. 

Table YII. 

Patient v. 

No. of red corpuscles Remakks. 

in 1 cubic mm. 

June 6, 5,365,125. Has averaged gr. j protiodide of mercury daily for four 

months. Has gained in weight : feels perfectly well. 
June 27, 5,302,375. Has gradually diminished dose, taking lately gr. i daily. 

Myself. 
Sept. 10, 4,775,275. Just from the countrj-, perfectly well. To take ! gr. prot- 
Sept. 20, 5,572,200. iodide mercury three times a day for two weeks. 
Sept. 24, 5,175,875. Up greater part of last night with a patient; no appetite 

for breakfast. 
Sept. 25, 5,562,062. Slept well and was abundantly hungry for breakfast. 

Patient v ranked far above average after taking mercury for four 
months, during most of which time he was perfectly well, for his chan- 
croid healed kindly ; but the result, in his case, was partly due to his 
living a more regular life, which his chancroid frightened liim into. 

As for myself, I started at about my healthy average (see Table I.), and 
gained over 700,000 in two weeks. I made no change whatever in ray 
mode of life, and took the extra precaution to get Dr. Stimson to make 
my count on each occasion, he being ignorant what manner of experi- 
ment I was subjecting myself to. My loss by one night's watching was 
made up by the next night's rest. 

Conclusion. — From what has been written, it seems fair to conclude 
that — 

1. 5,000,000 red blood corpuscles in the cubic mm. is a full, high ave- 
rage for the adult healthy male. Angemia very rarely goes below 
3,000,000; fine conditions of physical health reach above 6,000,000. In 
ordinary seasons, in the city, 4,500,000 would indicate a fair state of 
health. (Table I.) 

2. Mercury decreases the number of the red cells when given in excess, 
especially in hospitals (Wilbouchewitch). (Tables IV. and VI.) 

3. Syphilis diminishes the number of red corpuscles below the healthy 
standard. (Table II., first counts.) 

4. Mercury in small doses continued for a short or for a long period 
in syphilis, alone or with the iodide of potassium, increases the number of 
red corpuscles in the blood, and maintains a high standard of the same. 
(Tables II., III., and V.) 

5. Mercury in small doses acts as a tonic upon healthy animals, in- 



1876.] Morton, Xcuralgic Affection of Foot. 8T 

creasing their weight (Liogeois, Bennet's report, above referred to). In 
larger doses it is debilitating or fatal. 

6. Mercury in small doses is a tonic (for a time at least) to individuals 
in fair health, not syphilitic. In such individuals, it increases the number 
of the red blood corpuscles. (Table VII.) 

210 Madison Avem-e, New Yokk, Nor. 15, 1S75. 



Art. II. — A Peculiar and Painful Affection of the Fourth Metatarso- 
phalangeal Articulation. By Thomas G. Morton, M.D., one of the 
Surgeons to the Pennsylvania Hospital, Surgeon to the Philadelphia 
Orthopaedic Hospital, etc. (With two wood-cuts.) 

During the past few years, I have had under my care a number of cases 
of a peculiar and painful affection of the foot, which, so far as I am aware, 
has not been described. 

In these cases the pain has been localized in the fourth metatarso- 
phalangeal articulation ; in several instances it followed at once after an 
injury of the foot, in others it was gradually developed from pressure, 
while in others there was no recognized cause. 

Case I. — Mrs. J., the mother of three children, consulted me in July, 
1870, and gave the following history of her case : — 

"During the summer of 1868, while travelling in Switzerland, I made 
a pedestrian tour to the Valley of the Fanlhorn Mountain, and when 
descending a steep ravine, I trod upon quite a large stone which rolled 
from under my foot, causing me to slip, throwing my entire weight upon 
the forward foot ; though not falling, I found my right foot injured ; the 
pain was intense and accompanied by fainting sensations. With consider- 
able difficulty I reached the valley of the Grindenwald, where for hours I 
endured great suffering. After this I found it impossible to wear a shoe 
even for a few moments, the least pressure inducing an attack of severe' 
pain. At no time did the foot or toe swell or present any evidence of 
having been injured. During the succeeding five years the foot was never 
entirely free from pain, often ray suffering has been very severe, and coming 
on in paroxysms. I have been able only to wear a very large shoe, and only 
for a limited space of time, invariably being obliged to remove it every 
half hour or so, to relieve the foot. Much of the time I have gone with- 
out any covering except a stocking, and even at nights have suffered 
intensely ; slight pressure of the finger on the tender spot causes the same 
sensation as wearing a shoe. During the past year or so I have walked 
but little, and have consequently suffered much less." 

In this case, succeeding a contusion of the foot, acute pain came on, 
which continued for several hours. This was followed by permanent local 
sensitiveness, increased to absolute pain with the slightest pressure of a 
shoe, or even sock ; and at times, without any pressure or known cause, 
there would come on paroxysms of excessive pain. The neuralgia was 



38 Morton, Neuralgic Affection of Foot. [Jan. 

always referred to the raetatarso-pbalangeal joint of the fourth toe; dur- 
ing the severe paroxysms it extended, occasionally, to the knee. There 
was neither redness nor swelling anywhere about the foot. The head of the 
fourth metatarsal, with the phalangeal base, and the soft parts about the 
joint, were exceedingly sensitive. From the entire absence of all inflamma- 
tory symptoms, it seemed as if there might be, to account for the severity 
of the paroxysms, either a neuroma or some nerve hypertrophy. This sen- 
sitive condition was constantly aggravated by the almost unavoidable 
pressure of the very movable fifth metatarsal and little toe upon the fourth 
metatarso-phalangeal joint. A deep excavation in the sole of a broad 
shoe, corresponding to the joint of the fourth toe, was recommended ; this 
with varied anodyne applications to the part gave no marked relief. The 
least pressui'e of a shoe, and sometimes even that of a stocking, pro- 
duced a recurrence of intense pain. The patient was of a nervous tem- 
perament, with a predisposition to pulmonary disease, and was not in a 
condition to undergo any treatment which would confine her to the house. 
In June, 1873, I saw Mrs. J., again; then in consultation; there had 
been during this interval no improvement. A short time before seeing 
this patient the second time, I had under my care another case which pre- 
sented the same form of neuralgia, which followed an injury, and was suc- 
cessfully treated by an excision of the fourth metatarso-phalangeal joint. 
Neither Dr. Ellvvood Wilson nor myself thought it advisable then to re- 
commend this operation to our patient. 

Case II. — In March, 1873, I was asked to see Miss H. S., aged twenty- 
six, who, while in Europe four years before, injured her right foot upon a 
stone; had sudden intense pain, followed by slight swelling and redness. 
From the date of the injury localized pain in the foot continued, more espe- 
cially while wearing a shoe. The pain was referred to the head of the fourth 
metatarsal bone. There was a constant distress in the part, often of a sick- 
ening character. After wearing a shoe pain came on with great force, and 
at such times the shoe had to be instantly removed, the least delay causing 
a paroxysm of intense suffering. The boot or shoe was removed so often 
that a loose slipper was substituted. A marked lameness was induced by 
the patient's endeavours to spare the foot while walking. My friend Dr. 
William Hunt examined this case on several occasions in consultation. 
The pain was always found in the head of the fourth metatarsal, and the 
base of its associated phalanx. The pressure in this region induced violent 
pain, which extended up to the limb, was most severe when pressure was 
made upon the base of the first phalanx of the fourth toe, by the finger 
being brought in contact with this portion of the bone, so prominenily 
felt between the fourth and fifth toes; rest, anodyne and other applications 
failed to relieve the patient. Dr. Hunt agreed with me in recommending 
an excision of the painful joint and adjacent soft parts. 

Oper'ation. — After etherization on March 22d, 1873, an incision two 
inches in length was made on the outer edge of the extensor tendon of the 
fourth toe ; the metatarso-phalangeal articulation was then excised ; at the 
same time a portion of the shaft of the metatarsal bone was removed, 
with a quarter of an inch of the shaft of its associated phalanx. 

The wound was brought together with silver wire ; a free suppuration 
ensued, the wound closed up firmly in the course of five weeks ; the toe 
was shortened half an inch. This patient has visited Europe twice since 
the operation, and has had no further difficulty. 



187C.] Morton, Neuralgic AITuotioii of Foot. 39 

Tlie relief which followed was due not oiil3'to tho removal of the joint 
of the fourth toe, which from injury and subsequent pressure was ren- 
dered highly sensitive, but in the surrounding soft parts the nerves dis- 
tributed about the joint were also necessarily excised. There was no 
evidence of disease in the parts removed. 

Not long after this, the following case, which had not been benefited by 
any treatment, was sent me by Dr. Davidson. 

Case III. — Mrs. C, in April, 18*73, placed herself under my care, and 
gave me the following account of the painful affection which for twenty 
years had been a source of infinite trouble. "When 14 years of age, 
while jumping on a hard floor I slipped and fell, and at the time felt 
something give way in ray foot; very severe pain followed, and for some 
five years afterwards T experienced in the foot a sensation of want of sup- 
port ; pain was felt during all this period, and has since continued. While 
walking pain would come on so suddenly, that I would seek the nearest store 
or step, remove my shoe, manipulate the foot, and gradually the pain would 
subside, leaving the foot, however, very sensitive. Pressure of a slipper, 
stocking, or even the bedclothes, at times has been sufficient to bring on 
an attack. There has never been any swelling or redness in the foot." 

The head of the fourth metatarsal bone and base of the associated 
phalanx were found to be in a very painful condition. In all respects the 
case was similar to those already observed; the patient otherwise enjoyed 
excellent health. 

The operation of excision, as previously described, was performed April 
1, 1873; the wound quickly closed up, with the toe shortened half an inch. 
An ordinary shoe has since been worn with entire comfort, and there has 
been no recurrence of pain. 

Case IY. — In the following year Mrs. W. D. K., aged thirty, came to me 
with a similar neuralgia of the foot; as far as known there had been no 
direct injury, and the pressure of a shoe was supposed to be the cause; 
the pain was trivial at first, and gradually increased, at times was quite 
severe; the pain was of a burning nature, soon followed by a twisting 
cramp, coming on soon after wearing a shoe. A slipper was generally 
worn even in the street, and in the house this was often dispensed with ; 
the foot presented a normal appearance; direct pressure caused the pain, 
which was found in the same region as in the other cases. The patient 
was nursing an infant at the time of the examination. 

Case V.— I saw with Dr. Budd, of Mt. Holly, Oct. 20, 1874, a stout, 
healthy lady, 50 years of age, from Gloucester, N. J. Her history was 
so very like the cases already given that I was led to believe that her 
neuralgia was of the same nature. She had been a sufferer for many years, 
and no treatment had given any relief. Pressure made on the head of the 
fourth metatarsal provoked a severe attack of pain. She had often been 
treated under the impression that her malady was gout or rheumatism, but 
no careful examination of the foot had ever been made. 

Case VI. — Dr. M. W. Alison, of Hagerstown, Maryland, called upon 
me May 20, 1875, with a note of introduction from Dr. Reuling, of Balti- 
more. Dr. Alison told me he was seeking relief from frightful neuralgia 
in his right foot, which had existed for some years, and was gradually get- 
ting worse, and stated that he was willing and ready to submit even to 
amputation of the leg. 



40 MoRTOX, Xeuralgic Affection of Foot. [Jan. 

The history of this case at once, after an examination of the foot, 
demonstrated that the disease was the same as those already observed, 
save tliat the neuralgia was far more severe than in any one of the other 
cases. Dr. Alison was quite satisfied with the result of his visit, and soon 
afterwards, at my request, sent me the following history of his case: — 

"About six years ago I experienced an unpleasant painful sensation in 
ray right foot, which possibly originated in a strain ; the pain was first 
observed in the fourth metatarso-phalangeal region ; in the course of a 
fortnight it was followed by most violent pain, which was simply unbeara- 
ble, and so severe that it terminated in a convulsion. A painful condition 
of the parts followed, and with the least provocation, wearing a shoe or 
boot, sometimes without known cause, paroxysms of intense pain re- 
turned at various intervals, lasting from one to forty-eight hours. The 
pain, with one or two exceptions, has been confined entirely to the section 
of the foot indicated. My suffering has been beyond all comprehension ; 
very often I have been compelled to jump from my buggy, or stop while 
walking, remove my boot, which has always been of ample size, apply 
ligatures to the limb or foot, use hypodermic injections of morphia, fric- 
tions, or call upon some one to assist me by standing on the foot. This 
affliction has been the burden of my life, and this burden has been in- 
creased after consulting many eminent medical men, who gave me no satis- 
faction as to the nature of the disease, nor even suggested a hope of relief; 
my health otherwise has been uniformly good. I am satisfied the cases 
you have had are similar to my own save in the intensity of my sufferings, 
and I shall gladly submit to the operation you have suggested." 

Dr. Alison returned to the city on the lith of June, and was then care- 
fully examined, at my request, by Drs. William Hunt and Albert Fricke. 
We found that the neuralgia was unquestionably located in and about the 
head and phalanx of the fourth toe; even the slightest pressure or hand- 
ling could not be tolerated. The paroxysms of suffering which the doctor 
had, forcibly reminded me of those cases of severe facial neuralgia which 
I had several times seen in the second branch of the fifth pair of nerves. 

Operation. — June 15th. After etherization I made a longer incision than 
in the other operations, on the upper and outer side of the fourth metatar- 
sal bone, the shaft of which was divided rather more than half an inch 
beyond the head of the bone; the base of the first phalanx was also re- 
moved ; the toe was then found to be so isolated that at Dr. Hunt's sug- 
gestion it was removed ; the adjacent soft parts were dissected away to 
insure the excision of all the surrounding nerve branches; the wound was 
brought together with silver wire, and dressed with dry charpie. Dr. Alison 
was so well on the third day that he left for his home in Maryland. 

Dr. Alison writes: "Am happy to report all right; have not experi- 
enced any pain whatever, and am feeling better than I have for years, and 
feel assured that the operation will give me permanent relief" 

The excised parts, which presented no evidence of disease, were examined 
by Dr. Fricke, who reported — 

"Septembers, 1875. The portion of the foot removed by you in the 
case of Dr. Alison, of Hagerstown, I carefully examined. The nervous 
structures were all healthy, as proved by microscopic examination ; the 
only abnormal condition 1 found was a small abrasion upon the articular 
surface of the fourth metatarsal with the phalanx, not sufficient, it would 
seem, to account for the excruciating pain the doctor suffered. Dr. J. G. 
Richardson, who, likewise, at my request, examined the specimen, arrived 
at the same result." 



187G.] Morton, Neuralgic Affection of Foot. 41 

Case YII. — Mrs. C. H. K., of tliis city, a lady of fifty years of agi', 
who was under my care in August last, sent me the following note: "'The 
queer feeling,' I have been accustomed to call it, which has been in my left 
foot for thirty years, is a painful condition. The pain is in and about the 
joint of the fourth toe, with occasional attacks of intense suffering, when 
the pain extends to the knee, ami if my shoe is not instantly removed when 
the attack comes on, the pain reaches the hip. It does not matter whether 
I wear a large or a small shoe, as I have never worn a tight one, but it 
seems that the least pressure will produce the same result. Often my suf- 
ferings have been exceedingly acute, and coming on without any warning. 
Once I was taken while walking in the street, and the agony was so great 
that I was compelled to rest on a stoop, remove my shoe, and walk some 
distance in ray slocking alone, the pain running in a straight line to the 
hip-joint. I then consulted Dr. Joshua Wallace, and was asked 'if there 
was any gout in the family.' In September, 1868, while at the Academy 
of Music, I had an unusually severe attack, and not removing my shoe as 
quickly as I should have done, was obliged to walk to my carriage without 
the shoe, and suffered intensely for three hours. My eldest sister has been 
similarly affected still longer than myself, but in her right foot, same toe 
and joint. She has several times given up wearing shoes, but the attacks 
continued. She has not suffered so much during the past four years. Two 
of my friends suffer in like manner at the present time. In one of the 
cases the pain is relieved by placing the foot on the ground with the shoe 
off, and thus spreading the toes. In neither of the cases I have known is 
there any deformity or lap of the toes." This patient's foot was examined 
by Drs. Hunt and Fricke ; we could not advise an operation on account 
of an otherwise infirm state of health. 

Case VIII. — Lately, in consultation with Dr. Cleveland, of this city, I 
have seen two other cases. The first in September last, a Mrs. H., aged 
thirty-five years, and in the enjoyment otherwise of e.xcellent health. She 
has suffered from this painful condition of the foot for many years ; her 
history hardly varied from several of the previous cases. I found, however, 
a much greater lameness than before observed. 

Case IX. — The other case was a Mrs. G., aged thirty-four, from Maine. 
The neuralgia appeared rather suddenly, some four years ago; the patient, 
being at the time in the far West, was unavoidably obliged to wear a pair 
of badly-fitting, ready-made shoes, which at once induced the same painful 
condition in both feet. 

The pain at times has been exceedingly acute, and has never yielded to 
treatment. In this case the same joint in each foot was likewise affected 
with great lameness. 

Case X. — Mrs. R., aged twenty-eight, from New York, consulted me at 
the Orthopaedic Hospital October 14, 1875, and gave the following account : 
" Some ten or twelve years ago, while skating, I injured my left foot, was 
attended by Dr. Rhoads of Germantown, who supposed at first that a 
tendon had been ruptured, but this opinion was not confirmed. My suf- 
ferings were very acute, and I was confined a long time to my room. After 
this, neuralgic attacks came on, sometimes at night without cause. I have 
always referred the pain to the joint of the fourth toe. For many years I 
have carried about me a vial of chloroform, the only application which 
has ever relieved the pain, and this is now losing its effect." The slight 
examination I made brought on an attack of pain, which was confined to 



42 Morton, Neuralgic Affection of Foot. [Jan. 

the metatarso-phalangeal articulation of the fourth toe ; the foot was in all 
respects normal, the pain had always been confined to the part of the 
foot named. 

In addition to the cases narrated, I have seen three other examples of 
this neuralgia which need not be detailed. In one instance the neuralgia 
came on gradually, while in the two others it followed at once after injury. 

Several medical friends, with whom I have conversed on the subject, dis- 
tinctly call to mind cases of this malady which they have unsuccessfully 
treated. 

Case XI. — Dr. John F. Meigs tells me that one of his patients unques- 
tionably had this form of neuralgia for at least forty years. The paroxysms 
were very severe, and during the intervals, there was a continued painful 
state of the foot, no treatment ever gave relief, and the patient suffered 
until the time of her death. 

My friend Dr. J. G. Richardson, who examined the portion of the 
foot removed from Dr. Alison, sent me, under date of October 16, 18T5, 
the following account of a case which occurred some time ago in his own 
practice. 

Case XII. — Mrs. D. S., aged forty-eight, the mother of six children, a lady 
of highly sensitive and delicate organization, consulted me in the autumn 
of 1872, on account of paroxysms of suffering in her right foot, which, 
although only occasional, were sometimes intensely severe. The pain was 
seated beneath and around the fourth metatarso-phalangeal articulation, 
and seemed to be brougiit on especially by pressure of a new or tight boot, 
and was generally relieved by removal of the shoe, by the application of 
cold, or by painting with Fleming's Tincture of Aconite, as prescribed by 
a previous medical attendant. Whilst the neuralgic nature of these 
agonizing attacks appeared obvious, and the probal)le advantage of some 
surgical procedure was suggested, yet their true cause was not at the time 
recognized, although on retrospection I am satisfied that their character 
was analogous, if not identical, with those occurring in the jiatients who 
have been fortunate enough to fall under your care. 

From the number of cases which have been observed it would appear 
that the affection is not so uncommon, only that, as a distinct disease, it 
has not heretofore been noticed. Of the twelve cases which I have re- 
ported, eleven have occurred in females. Besides these I have had three 
other cases, making a total of fifteen ; the neuralgia in eight of the cases 
was clearly traced to a direct injury of the joint of the fourth toe. In 
three or four of the cases it originated from shoe-pressure ; and in the 
remainder no cause for the pain was assigned. 

The neuralgic paroxysms, and subsequent sensitive condition of the 
joint referred to, in some cases after continuing a variable period, without 
apparent cause, became less and less severe ; inflammatory symptoms were 
not observed in any of the cases. 

In several instances where this neuralgia followed an injury, a rupture 



1876. J M oil TON, Neuralgic Affoctioii of Foot. 43 

of the ligaments or parts about the joint of the fourtli metatarsal was 
supposed to have occurred. 

Of the fifteen cases, thirteen were in females, and two were in males. 
All of the patients, it may be stated, were surrounded, not only by the 
comforts, but in most instances were accustomed to the luxuries of life. 

The portions of the foot which were excised were carefully examined. 
In two instances nothing abnormal conld be found ; in the third case (Dr- 
Alison's), an abrasion or indentation was found on the outer })art of the head 
of the fourth metatarsal, which was so slight, however, that it did not seem 
to beat all likely to be the cause of the terrific pain, but was unquestionably 
the result of the pressure of the fifth metatarsal. With this exception the 
parts were healthy. A vertical section through the head of the metatarsal 
and phalanx showed no evidence of any disease.^ 

An examination of the anatomy of the metatarso-phalangeal region 
will more readily explain the occurrence, under certain circumstances, of 

' Tlie following note, from ray friend Dr. Jolin H. Packard, in regard to his own 
case, illustrating this same form of foot neuralgia, was received since the above 
article was placed in type : — 

"For several years previous to 1864, I had been subject to occasional disloca- 
tions of a relaxed joint in tlie fouith toe of my right foot. They had always 
occurred in walking, and the symptoms were perfectly distinct ; the reduction, 
which was usually efifectod without difficulty, by simply 'working' the toe, was 
equally unmistakable. 

" In the summer of that j'ear, I was climbing a mountain, when the joint became 
displaced ; and, as it would speedily have slippeil out again if reduced, I allowed 
it to remain luxated until I had finished the ascent, and returned to the base ; 
when the pain was so great as to make it necessary for me to ride home. After 
several hours of suffering, the joint gradually I'esumed its normal state. 

" Since that time, I do not remember that the luxation has ever taken place ; but 
I have had many attacks of neuralgic pain in the part, coming on generally after 
exercise, but sometimes after sitting in one position, as in my carriage. Often 
exercise does not induce it. Heat, as from the pavements or the sand in summer, 
is a much more frequent caiise. It begins gradually, and sometimes wears away 
in the same manner, but sometimes vanishes suddenly, as if by magic, without 
the use of any means of relief. The piessure of a boot always aggravates it, but 
it has attacked me while in bed at night. Diversion of the mind will often allay 
it, but it sometimes comes on again afterwards with far greater severity. 

" In 1SG9, while spending most of the summer at Atlantic City, I suffered more 
from this trouble than ever before or since. It would then often come on at night, 
after a day in town ; and once or twice the attacks lasted more than twenty-four 
Lours. So great was the annoyance from it, that I proposed amputation of the toe 
to a surgical friend, but he advised me against it. Since then it has been much less 
troublesome, though I have sometimes had it more or less every day for a week. 

" Deep pressure over the metatarso-phalangeal joint is painful, but does not bring 
on an attack unless long continued. Cold has given me more eflectual relief than 
any other remedy I have tried." Philada., Nov. 24, 1875. 

In this case it would appear, that the neuralgia was in the first place caused 
by a sudden malposition of the metatarso-phalangeal joint of the fourth toe ; 
incident either to a relaxed state of the joint, or to a partial rupture of the liga- 
ments, which allowed the head of the bone to slip from its phalangeal articula- 
tion, thus subjecting the parts to unusual pressure. 



44 



Morton, Neuralgic Afifection of Foot. 



[Jan. 




Fig. 1. neuralgia in this locality. The metatarso- 

phalangeal joints of the first, second, and 
third toes are often found on a line with each 
other ; the head of the fourth metatarsal is 
found to be from one-eighth to one-fourth of 
an inch behind the head of the third ; while 
the head of the fifth is from three-eighths to 
half an inch behind the head of the fourth. 
Thus, while the joint of the third is slightly 
above, the joint of the fifth is considerably be- 
low the metatarso-phalangeal articulation of 
the fourth. 

The joint of the fifth metatarsal being so 
much posterior to that of the fourth, the base 
of the first phalanx of the little toe is brought 
on a line with the head and neck of the fourth 
metatarsal, and the head of the fifth opposite 
the neck of the fourth (see Fig. 1). 

There is very slight lateral motion in the 
first three metatarsal bones, on account of 
their peculiar tarsal articulations ; this is not 
so with the fourth and the fifth, which have 
much greater mobility, the fifth considerably 
more than the fourth, and in this respect it 
resembles the fifth metacarpal. It will be found that lateral pressure 
brings the head of the fifth metatarsal and the little toe into direct contact 
with the base of the first phalanx, and head and neck of the fourth, and 
to some extent the extremity of the fifth metatarsal rolls above and under 
this bone. 

The externa] plantar nerve gives off superficial and deep muscular 
branches, the superficial branch separates into two digital nerves, which 
supply the outer and inner side of the fifth toe, and the outer side of 
the fourth ; small branches are distributed freely between the fourth and 
fifth toes, about the metatarso-phalangeal joints (see Fig. 2). 

To the peculiar position which the fourth metatarso-phalangeal articu- 
lation bears to that of the fifth, the great mobility of the fifth metatar- 
sal, which by lateral pressure is brought into contact with the fourth, and 
lastly, the proximity of the digital branches of the external plantar nerve, 
which are, under certain circumstances, liable to be bruised by, or pinched 
between the fourth and the fifth metatarsals, may be ascribed the neural- 
gia in this region. 

From dissections of the female foot, I find that the fourth metatarso- 
phalangeal joint has the same relative position to the third and fifth as 



The limb from which ibis foot 
was obtained, I amiiutated at the 
Pennsylvania Hospital on account 
of railroad injuries in Sept. 1S75. 
That patient was a labouring man, 
aged 28. 



1876.] 



SiiAKEsrEAUK, Xc'w Oi»litli;ilinoscope. 



45 



observed in the male foot — so that the 
affection, vvhieli has been seen more fre- 
quently in females, may be attributed not 
only to the greater delicacy and pliability 
of the female foot, as compared with the 
male foot, but perhaps in a measure to 
the prevailing custom, especially with 
fashionable women, of wearing tight and 
very narrow shoes. The fifth metatarsal 
is thus pressed against the head and 
neck of the fourth metatarsal — the pha- 
lanx of the fifth esi)ecially is forced down 
upon the head of the fourth and its 
associated phalanx — the toes generally 
are irregularly crowded together, and a 
painful condition of the foot may be in- 
duced, and this kept up undoubtedly 
predisposes to more serious consequences. 

In cases where this form of neuralgia 
has been suddenly induced by an injury, 
the treatment should be vigorous local 
blood-letting, anodyne applications, with 
long-continued rest, until all sensitiveness 
of the joint has disappeared. 

In chronic cases, such as have been 
described, no other treatment except com- 
plete excision of the irritable metatarso- 
phalangeal joint with the surrounding 
soft parts will be likely to prove perma- 
nently successful. 




From Henle, reduced one-third ; show- 
ing the plantar nerves with the digital 
branches of the external plantar to the 
fourth and fifth metatarso-phalangeal 
articulations, with the deeper branches 
to the same region. 



Art. III. — Description of a New Ophthalmoscope and Ophthalmometer, 
devised for Clinical Use and for Physiological and Therapeutic In- 
vestigations upon Man and Animals. By Edward 0. Shakespeare, 
A.M., M.D., of Philadelphia. (With four illustrations.) 



The ophthalmoscope, as a useful instrument, was an impossibility as 
long as scientists failed to recognize, in the refractive apparatus of the 
eye, a mechanism by which objective images could be formed upon the 
proper sentient membrane. The action of lenses upon the course of 
luminous rays was, however, tolerably well recognized long before it was 



46 Shakespeare, New Ophthalmoscope. [Jan. 

generally acknowledged that the retina was a enrtain upon which was 
formed an inverted image of an object placed before the eye. History 
informs us that it is to Kepler we owe the first suggestion of inverted 
retinal images. To Helmholtz must be awarded the credit of first com- 
prehending and surmounting the difficulties in the way of a definitive 
view of the retinal surface, and the glory of conferring upon humanity the 
blessings which have followed, and are yet to come from the skilful use of 
the ophthalmoscope. "Auscultation and percussion have not rid the his- 
tory of thoracic affections of more errors than have been swept from 
ophthalmic surgery by the ophthalmoscope." In the conquests of this 
little instrument, " one no longer hesitates to recognize the magnificent 
results of one of the most beautiful applications of physics to medicine." 
These results have been characterized as magnificent, and the term is 
seldom more fittingly applied. Of the sensory organs with which man is 
endowed for communion with what is beyond him, the eye contributes most 
to his happiness and the comprehension of his relation to the universe. 
Looking at the ophthalmoscope in the light of the past alone, its usefulness 
has been sufficient to gain for its discoverer enduring renown. But when 
one reflects that in the years which have passed, ophthalmology has 
scarce completed its infancy, and that a not very distant future promises 
for it a full development into a comparatively exact science, one may well 
conceive the value of the ophthalmoscope to be almost inestimable. 

Since the construction of the first ophthalmoscope of Helmholtz, nu- 
merous modifications have appeared. Space will not permit, nor is it 
our intention in the present paper, to review the history or discuss at 
any length the merits of these modifications, some of which are important 
improvements. The general reader to whom such questions are of in- 
terest is referred to special works on the construction and use of the 
ophthalmoscope, among which that of Zander is considered to hold front 
rank. 

In presenting to the profession the optical instrument described below, 
I have ventured to call it a "New Ophthalmoscope and Ophthalmometer," 
because it is believed to be, for the most part, unique in design, partly 
new in principle, and entirely original in some of its applications both as 
an ophthalmoscope and as an instrument for measuring the eye. To 
make this title descriptive of the whole instrument, however, another word 
might be added which should indicate that it also supplies a means by 
which the eye-ground can be accurately drawn. The instrument may be 
conveniently used either as a portable or stationary one, and arranged for 
the examination of the eye either by the direct or indirect methods. 

Fig. 1 represents in full size a bird's-eye view of the essential parts of 
the instrument,' and illustrates the principle of its construction and use. 
D is a bar, upon which is fastened a biconvex lens L, corrected for 
spherical and chromatic aberrations. Its focal length is about j%- of 



1876.] 



Shakespeare, New Ophthalmoscope. 



47 



an iiu'h, and its principal axis is parallel with the l)ar. Upon the 
same bar is placed a holder ii, so that it may lie moved backwards and 
forwards between L and c. The movement of the holder upon the bar D 
is effected by turning the screw s. Tliis screw is so fitted in the shoulder 





^T 



€ 






Fj.3 




M^.4. 




B 



F, that daring a revolution its position relative to the shoulder and the 
bar remains unchanged. Upon the whole length of the screw beyond this 
shoulder threads are cut forty to the inch. The threaded part of the 
screw turns in the holder h. The head of this screw is a half inch in 



48 Shakespeare, New Ophthalmoscope. [Jan 

diameter, and is divided into tenths. A movement of the fortieth of an 
inch is thus given to the holder by au entire revolution of the screw, 
while one-tenth of a revolution will give a movement of one four- 
hundredth of an inch. Upon the shoulder f is placed a cylinder c, whose 
axis is coincident with the principal axis of the lens L. The bar, from 
the position of the lens l to its extremity at d, is expanded into a circular 
disk, in the centre of which, at o, is a round opening, about equal in 
diameter to that of the normal pupil. To the back of this disk are 
fastened spring clips G, intended, when necessary, to support behind the 
opening o, a proper lens. At M is fixed a mirror, consisting of extremely 
thin, silvered glass. Its plane is inclined at an angle of 45^ with the axis 
of the lens L, and at the point where an imaginary line in the axis of the 
aperture o would intersect the mirror, its surface, for a very small space, is 
devoid of the silver coating. In the collar by which the lens L is fastened 
to the bar, and parallel with the latter, is a smooth hole for the reception 
of the handle, or the support for the instrument. E is a small clamp 
screw, by which, when the handle is fixed in the hole, the instrument may 
be prevented from turning upon the former. The whole instrument, how- 
ever, when it is desirable, is capable of performing a semi-revolution upon 
the axis of this hole. AYhen the instrument is to be made stationary, 
instead of being attached to the handle it is made fast to a stand. This 
stand is provided with a chin rest, capable of being raised or lowered 
within certain limits. The support for the instrument is so constructed 
that the ophthalmoscope may move vertically or horizontally to describe 
an arc upon its axis as radius, in such manner that the centre of this 
movement may be made coincident with the centre of motion of the eye. 

The source of illumination is the flame of a small lamp or gas jet in- 
closed within a narrow opaque chimney, shown in Fig. 2 half size. In 
the side of the chimney, and on a level with the most brilliant part of the 
flame, is a small round hole for the transmission of light to the condens- 
ing lens N fixed in the end of a tube joined at an angle of 90'^ with the 
chimney. The focal length of this condensing lens is about half au inch, 
and the distance of its centre from the flame is twice the focal distance, 
so that the light from the flame is condensed at a point on the other side 
of N, at a distance from it equal to twice that of its principal focus. The 
tube carrying the condensing lens x, fits into the cylinder c, and, within 
certain limits, may be moved backwards and forwards. The cylinder c is 
the sole support for the source of illumination. The movement of the con- 
densing lens within the cylinder secures a considerable motion of the flame 
image within or without the position of the principal focus of the lens L, 
and permits of the illumination of the eye either by parallel divergent or 
convergent rays at the pleasure of the surgeon. 

As a portable ophthalmoscope the manner of using scarcely needs ex- 
planation. The luminous rays which are condensed by the lens N, strike 



1876.] Shakespeare, New OplitlKiliuoscojie. 49 

the lens L as if emanating: from the image formed by x of tlie \am\) flame, 
and after refraction, issue from l in the direction of k, but before reaching 
this point they will be reflected by the plane-silvered mirror M in the direc- 
tion of A. If the eye to be examined l)e now placed at A, it is obvious that 
its fundus will Ije illuminated. Tlie light by which the fundus is to be 
seen retraces the course of the illuminating pencil as far as the mirror, 
passes through its desilvered portion, penetrates the aperture o, and pro- 
ceeds towards b. When the surgeon's eye is placed at b, it is in the 
proper position for the examination of A by the direct method. If it 
be desirable to view the inverted image, a convex lens of the proper focal 
length is dropped into the spring clips G, and the eye of the surgeon 
moved backwards until the distance at which the aerial image may be well 
seen is reached. What has been indicated above will suggest an explana- 
tion of the use of the instrument as a stationary ophthalmoscope. Before 
passing from the consideration of the instrument as an ophthalmoscope, 
it may be mentioned that, when fixed upon its stationary stand, and 
arranged for examination of the inverted image, the barrel of a microscope 
can be conveniently attached, so that the retina as far as Is practicable 
may be seen under a higher magnifying power than that by which it is 
ordinarily viewed. 

It is believed, however/, that the chief value of this instrument is to be 
associated with its use as an ophthalmometer. In this regard it is de- 
signed, rapidly and correctly, to determine the refraction of the eye; to 
measure the distance of the retina behind the nodal point, and the actual, 
as well as relative size and position of any fixed visible object within the 
eye; to estimate and render possible the more perfect correction of certain 
forms of astigmatism which have been classed as irregular and irremedia- 
ble ; to measure the radius of curvature of the cornea in the different 
meridians ; to recognize the coincidence or want of coincidence of the axis 
of the lens with that of the cornea, and, if there be any deviation, to esti- 
mate the degree of eccentricity of their reflecting surfaces; and to deter- 
mine the position of the iris. 

In the discussion of these several points an endeavour will be made to 
observe, as nearly as possible, the order in which they have been stated. 

First, the refraction of the eye may be measured by this instrument in 
two difi"erent ways, both of which, nevertheless, rest upon much the same 
foundation. In the one method the patient, whether he be a dolt or a 
sage, is made the observer, and has therefore the opportunity to vitiate 
the result by means of his stupidity or the operation of his fancy ; while 
in the other, on the contrary, the correctness of the determination must 
depend alone upon the accuracy of observation of the examining surgeon. 
The principle common to each is that which is involved in the formation 
of retinal images. In illustration, suppose the eye whose refraction is 
to be determined, when accommodated for distance has its far point at 
No. C:XLI.— Jan. 1876. 4 



50 Shakespeare, Xew Ophthalmoscope. [Jan. 

twenty-four inches. This eye, then, is myopic, and in the condition 
imagined can have no other luminous rays sharply focused upon its retina 
except those which go to it as if emanating from some position twenty- 
four inches in front of its nodal point. The radiant point and the point 
upon the retina to which, after refraction at the posterior surface of the 
crystalline, the rays converge, bear to each other the relation of conjugate 
foci. When the innumerable points which compose any object are distant 
in front of the nodal point just twenty-four inches, then, and then only, 
can their images be sharply focused upon the retina. Since it is only by 
distinct retinal images that external objects are distinctly perceptible, the 
only possible position in which an object can be placed so that it may be 
perfectly seen by this eye, is such that the rays proceeding from the object 
must enter the eye as if emanating from a position twenty-four inches in 
front of the nodal point. 

Every eye has a certain degree of astigmatism. In the eye possessed of 
what is reckoned as normal acuity of vision, the length of focus of the 
meridian of greatest curvature is so nearly equal to the focal distance for 
the meridian of least curvature, that each focus may practically be con- 
sidered as upon the retina. When, however, the amount of astigmatism 
is sufficient to interfere with distinot vision, while the focus for one meri- 
dian is upon the rods and cunes of the retina, the focus for the opposite 
meridian is situated at an appreciable distance either in front of or behind 
this position. 

Without stopping to explain the rationale of the phenomenon, the effect 
of this anomaly of refraction upon the formation of images at the retina, 
and therefore upon the defined perception of external objects, is such that 
if an object consisting of fine and equally distinct radiating lines be placed 
at the proper distance in front of the eye in order to have formed upon 
the retina a defined image of the line which is at right angles with the 
meridian of least curvature, the line at right angles to the first must have 
its image formed in front of the retina, and will therefore appear indis- 
tinct. In order that this last line may be seen distinctly, it must be placed 
nearer the nodal point. Now, suppose the myopic eye which we have 
previously considered, have added to it an astigmatism of such degree that 
the anterior conjugate focal distance for the meridian of greatest curvature is 
twelve inches. In order that the eye may see distinctly the lines at right 
angles to the meridian of least curvature, the object must be placed at 
twenty-four inches ; but, in order that the lines in the opposite direction 
may be seen with equal distinctness, the object must be placed at twelve 
inches. Herewith are given the requisite quantities for calculating the 
curvature of the theoretical glass which would neutralize the refractive 
anomaly in the supposed case, and make the eye emmetropic. 

To make practical application of the principle enunciated above, let the 
instrument be fixed upon its stationary stand. Instead of placing at a the 



1876.] Shakespeare, Xew Oplithalmoscope. 51 

eye which is to lie examined, place it at K, and remove the mirror M, so 
that all the rays transmitted l»y the lens L may pass to the eye at K. 
The lamp is also to be removed, and is to be replaced by a plane mirror, 
so that ordinary daylight may be reflected through the cylinder c towards 
the lens l. A test object is now placed in the holder H, in such position 
that its centre shall be upon the principal axis of the lens l. This object 
may be a reduced i)hotograph of Snellen's test-types, a similar photograph 
of Green's tests for astigmatism, or it may consist of extremely fine wires 
stretched across the opening of a disk. For the measurement of the sup- 
posed myopic and astigmatic eye, we will select as object one of Green's 
figures, consisting of fine radiating lines, which divide the circle into equal 
parts of 6° each. By means of the screw s. Fig. 1, the object can be 
moved towards or separated from the lens l. The holder is first set at its 
greatest distance from L. Then as the object is slowly moved towards 
the lens, the patient is directed to observe which line becomes black and 
sharp first, and to notify the surgeon at the time it is seen with the 
greatest distinctness. The direction of this line is at a right angle to the 
meridian of least curvature. This direction is noted, as also the exact 
distance of the object from the central point of the lens L. The object is 
now made to approach the lens until the line at right angles to the first 
comes distinctly into view, when the distance of the holder is again noted. 
The distances from the lens L of the object and the image of it which is 
formed by the lens, have the relation of conjugate focal distances. The 
principal focus of the lens is known. The distance of the object being 
given, the distance of the image may be easily calculated. It is this 
image that the eye observes, and its position must be at the requisite dis- 
tance from the eye, else the rays apparently emanating from it cannot be 
focused upon the retina. When, tlierefore, the distance from the lens to 
the positions where the image must be formed in order that the lines shall 
be seen as above indicated is calculated, it is evident that the far-point for 
the meridians of greatest and least curvature have been measured. In the 
case considered, to these distances must of course be added the distance 
from the eye to the centre of the lens. Supposing the latter distance to 
be one inch, then when the line at right angles to the meridian of least 
curvature is distinctly seen, the position of the object with respect to the 
centre of the lens must be such that the image will be formed at twenty- 
three inches ; and when the line in the opposite direction is sharp, the 
object must be approached to the lens, until the position of the image is 
at eleven inches. 

For the measurement of a myopic meridian, the object must be placed at 
the proper distance within the principal focus of the lens L, so that the 
rays shall issue divergent to form an image erect and vertical. For the 
determination of a hypermetropic meridian, the object must be placed at 
the necessary distance beyond the principal focus, when the rays will pass 



52 Shakespeare, New Ophthalmoscope. [Jan. 

from the lens in the proper state of convergence, the distance from the 
eye to the lens being here deducted. While in the case of a normal or 
emmetropic meridian the position of the object must of necessity be i>re- 
cisely at the principal focus. 

The above method of estimating the refraction of the dioptric system 
may be supplemented by placing the object at the principal focus of the 
lens, when the rays, after refraction, will pass to the patient's eye parallel. 
The glass required to bring parallel rays to a focus upon the rods and 
cones may then be found by trial. Further, the lens (l, Fig. 1) may be 
fitted with a revolving disk perforated by a narrow slit, to be employed 
as an additional means for determining astigmatism. 

Let us at this point consider briefly the second method referred to above, 
in which the surgeon becomes the sole observer. The instrument is now 
to be used as an ophthalmoscope, arranged either for examination of the 
erect or inverted image of the fundus. The mirror m is to be refixed. 
The plane mirror behind c, removed and replaced by the lamp and con- 
densing lens N. The eye of the patient is to be placed at a ; that of 
the surgeon at b if the examination is to be direct, at the proper dis- 
tance behind B if indirect. The rays from the object, instead of passing 
to K, now are reflected into A, and may be focused upon the retina of the 
eye in that position, as well as when the eye was placed at K. The reti- 
nal image in the patient's eye now becomes the observed object, and the 
surgeon the observer. When an image of the object in h is formed upon 
the retina of A at which the observer is looking, at the same time that he 
sees the retinal surface he will also see the retinal image formed upon it. 
Thus the surgeon becomes the sole judge of the direction of the lines 
which are first and last imaged at the retina and of the sharpness with 
which they are focused upon that membrane. Hence in this manner he is 
supplied with the means of measuring rapidly and accurately the state of 
refraction of any eye, whether it be that of a human being, or of an unrea- 
soning animal. 

When the eye to be corrected is in the head of an intelligent being, the 
results of the two methods may be compared with each other, thereby fur- 
nishing an additional guard against error. If it be desirable to have the 
results of these two methods to compare the one with the other, and time 
be very limited, the second method may be employed first. As soon as the 
proper notes are made, while the instrument is still used in the manner 
last described the patient may be directed to observe the image himself, 
and state, as in the first method, when the different lines are most distinctly 
seen. The image must be then formed upon the macula. The observer 
sees it at the instant when the patient makes his observation, and can thus 
compare instantaneously his own observation with that of the patient. 
Here then both the patient and the surgeon become the observer at one 
and the same instant. 



1870.] Shakespeare, New Oplitlialmoscope. 53 

It is scarcely necessary in this connection to add any remarks upon the 
usefuhiess of these methods of determining the refraction of eyes in com- 
parison with those ordinarily employed. The advantages to be credited 
to the use of this instrnment in estimating anomalies of refraction are 
obvious and striking. It issufticient to mention two among several, viz., 
the great rapidity and accuracy of measurements, and the possibility of 
making reliable measurements of the refraction of eyes of young children' 
and of animals of lower orders of creation. 

The principles which govern the formation of images by lenses are again 
given practical a])plication in the employment of this ophthalmometer as 
a means for measuring the size and position of visible objects within the 
eye. The focal length of a lens, and the distance and size of an object 
])laced anywhere along the axis, being known, to calculate the position and 
size of the image is a very simple problem in optics. The magnitude of 
the image relative to that of the object is directly proportional to their 
respective distances from the nodal points of the lens. This is unques- 
tionably true of the image formed by the lens l, of any object in the holder 
H. To measure the diameter of a retinal vessel or the breadth of the optic 
disk, the instrument must be used as in the previously mentioned second 
method for the determination of refraction, but, instead of the photo- 
graph of Green's tests for astigmation as object, the contrivance repre- 
sented in Pig. 3 is placed in the holder, a is a brass plate pierced by a 
hole about three-eighths of an inch in diameter. Upon this plate a ring 
B, whose aperture is equal to and is set opposite that of the hole of the 
plate, is so fastened that it can be revolved upon its axis. U{)on the 
periphery of this ring is a mark, and upon the plate are scratched lines 
which may serve to indicate the degree of revolution. Two extremely fine 
wires, parallel to each other and to the diameter of the ring, are stretched 
across the aperture of the ring, and made fast at the ends. Between these 
two wires, and occupying the diameter of the ring, is another wire. This 
middle wire, however, is interrupted at the centre of the aperture. One of 
the ends is fastened immovably to the ring ; the other is connected with 
the screw d, which turns in the collar c. These three wires are in the same 
plane, so that vvhen the ring revolves they are always vertical to the axis 
of the lens L, Fig. 1. By turning the screw d, Fig. 3, the points of the 
middle wire can be approached or separated. The distance apart of the 
points is to be learned either by noting the number of turns of the screw, 
or by noting the distance the apex of the screw is raised above a mark 
scratched upon the ring. Another exact and ready means of measuring 
the distance between the points, is by focusing an image of them upon a 
finely divided rule placed at a known distance from the nodal point of the 
lens L, Fig. 1. After noting the number of divisions included between the 
points, the actual distance is calculated. 

As was stated when speaking of the methods of determining the refrac- 



54 Shakespeare, New Ophthalmoscope. [Jan. 

tion, it is the image formed by the lens l of the object in the holder h, 
that the patient's eye observes. The distance of this image from the eye 
and its size are known. When, therefore, tlie distance of the retina 
behind the nodal point is^ actually known, the size of the retinal image 
may be accurately calculated. The retinal image then is the standard of 
measurement of any part of the fundus. As this standard is absolute or 
only approximate, so must the measurement be absolutely correct or merely 
approximate. 

The measurement in the manner indicated below may be made either 
when the eye is perfectly at rest, that is, fixed for distance ; or it may be 
accomplished while the eye is accommodated for some near point. For 
special reasons which will be advanced later, it is always preferable to 
make these measurements when the eye has its tension of accommodation 
thoroughly relaxed. Suppose the eye whose optic disk is to be measured, 
accommodated for its most remote point ; further, let the state of refrac- 
tion be perfectly emmetropic. The far point of such an eye is at an 
infinite distance. Theoretically then only at infinity can an object be 
placed in order that rays proceeding from it may be focused on the retina. 
Practically, however, the far point of an eye set for parallel rays is suf- 
ficiently remote when placed, say, at a distance of a thousand yards. Let 
the far point of the supposed eye be at one thousand yards. For con- 
venience sake we will call the contrivance, illustrated by Fig. 3, a micro- 
meter. Now using the instrument as above indicated, the holder is moved 
backwards or forwards until an image of the micrometer wires is seen by 
the surgeon to be sharply focused upon the retina of the observed eye. 
This done, the distance of the ol)ject image in front of the observed eye is 
known. It must be one thousand yards. By a slight movement of the 
hand if the instrument is arranged as portable, by a slight movement either 
of the eye of the patient or of the instrument if the latter is fixed upon its 
stand, the image of the micrometer wires is thrown upon the optic disk. 
The ring of the micrometer is rotated until the wire images cross the disk 
in the particular direction desired. The micrometer points are then sepa- 
rated by means of the screw until their ocular images exactly coincide with 
the borders of the disk It remains to measure the exact distance between 
the micrometer points, and to calculate the distance between the images 
of these points when placed at one thousand yards. When this is done, 
two of the three factors necessary to the calculation of the actual distance 
between the ocular images of the micrometer points are given. It is 
unfortunate, however, for the completion of the calculation, that the dis- 
tance from the posterior nodal point to the retina, or the surface of the 
optic nerve, still remains an unknown quantity. This, the last of the three 
factors, is absolutely essential to the solution of the problem. 

It is chiefly at this point that all plans heretofore devised for the 
accurate measurement of the real dimensions of objects in the fundus oculi 



18TG.] Shakespeare, New Ophtlmlmoscope. 55 

have failed. The most accurate measurements of tliis kind, have been 
based upon the vahie of this univiiown factor as given by Listing in his 
schematic eye. This distance is tliere fixed at 15 mm. Counting then 
the distance between the posterior nodal point and the ocular image of 
the micrometer points as 15 ram., the breadth of the optic disk or any 
other visible object may, when the eye is emmetropic and its accommoda- 
tion at rest, be estimated with tolerable exactness by the method here pro- 
posed. In the emmetropic eye the variation of the estimated distance 
between the surface of the cornea and the anterior nodal point from the 
actual distance, and the distance between the nodal points are so infinitely 
small in comparison with the distance of the far point, that they may be 
disregarded entirely without affecting in the least the accuracy of the cal- 
culations. 

To recur again to the stumbling block that has been in the way of 
absolute measurements of intra-ocular objects. The distance between 
the posterior nodal point and the retina is an ever-varying quantity, the 
knowledge of which has hitherto defied alike the attempt of physicist and 
physiologist. It varies both with the state of refraction and accommoda- 
tion. Bonders declares his belief that the rationale of myopia or hyper- 
metropia is to be exclusively sought in the distance from the posterior 
nodal point of the crystalline to the retina, while Jaeger and other great 
authorities hold it as occasionally probable that the anomaly of refraction 
is due, at least in part, to an increase in curvature or density of the lens. 
Here then is added still another possible source of error. Again, where 
the accommodative power of the eye is allowed to be exercised, its influence 
upon the position of the nodal points is yet another factor whose actual 
value it is not possible to determine until their position in any given state 
of refraction with the eye at rest be positively known. Moreover, when 
measurement is made during accommodation for a very near point, to com- 
plicate the difficulty already mentioned as arising from the movements of 
the nodal points, another condition arises which makes it impossible to 
do more than closely approximate the actual anterior conjugate focal dis- 
tance of the eye. The plan devised by Epkens and Bonders for estimat- 
ing the size of retinal vessels, and adopted by those who have made the 
most reliable measurements, must necessarily struggle with every one of 
these difficulties, for by its employment the patient is made to accommo- 
date for a point about twelve inches from the eye. Nevertheless, the 
ingenious method first practised by the two eminent men just referred to, 
is by far the best and most satisfactory that has been heretofore proposed. 

It was stated above, that the method herein proposed will, when the 
eye is accommodated for distance, give tolerably accurate results. As 
compared with those heretofore employed, it has the advantages of 
avoiding entirely the causes of error lurking in the unknown effect of 
accommodation ; of being quickly and easily used without any particular 



56 Shakespeare, New Ophthalmoscope. [Jan. 

intelligence or previous training on the part of the patient; and of being 
used in investigations upon animals. Another of the advantages gained 
by its use is in the important fact, that, while the measurement is made, the 
refraction is at the same time determined, for when the wires are imaged 
upon the retina the refraction of the meridian at right angles to the direc- 
tion of the wires becomes known. It is believed then that here is a 
means by which the physician, the surgeon, the therapeutist, the physiolo- 
gist, the oculist, may from day to day, or from hour to hour, with little 
trouble and at little expenditure of time, satisfactorily study and note for 
comparison the state of the circulation, or indeed the visible exponents of 
any other process that is transpiring within the depths of the eye. 

By making a small addition to the instrument, as so far described, a 
second method of measuring the eye-ground is gained. Referring to Fig. 
4, it is seen that this addition is in the shape of a transparent glass mirror 
m', of plane parallel surfaces, which are separated the one-two-hundredth 
of an inch. Suppose the refraction of the eye known, and, if it is de- 
sired, the first measurement completed in the manner previously described. 
This extremely thin transparent mirror m'. Fig. 4, which has a means 
of moderating the light reflected into the surgeon's eye, is placed, as repre- 
sented in the figure, vertical to the surface of the silvered mirror m, so that 
the former is in contact with the latter along an imaginary line forming 
a tangent to that border of the aperture of the mirror which is most dis- 
tant from the lens l. About eight per cent, of the luminous rays which, 
after issuing from the lens L, impinge upon the mirror m', are reflected 
into the eye of the surgeon; the remainder are transmitted and pass into 
the patient's eye. The far point of this eye has been already determined. 
Now reverse the position of the micrometer so that the rays from it, after 
refraction by the lens L, and reflection by the mirror m', shall proceed as 
if convergent to the far point of A. It is obvious that these rays will 
come to B precisely in the same state as those which come from a. When 
therefore b sees the image of the eye-ground of A, he will also see projected 
upon it the image of the micrometer, both being equally distant from B. 
The image of the micrometer is projected upon the image of the disk, the 
points of the micrometer are separated until their images correspond with 
the circumference of the disk, and the optic disk is again measured. We 
have now for comparison two measurements of the same object made dur- 
ing the same state of refraction by two separate methods. 

A question may be alluded to here which is related both to the measure- 
ment of the anterior conjugate focal distance and to the distance from the 
retina to the nodal point. Frequently, indeed generally, in high degrees 
of myopia or myopic astigmatism, and sometimes in hypermetropic astig- 
matism, a more or less marked posterior staphyloma is found as a com- 
plication. Usually the apex of the posterior protrusion is somewhere 
between the optic entrance and the point of the retina intersected by the 



1876.] Shakespeare, New Ophthalmoscope. 5T 

optic axis. The effect of this condition upon the customary relation 
between tlie retinal surface and the visual a.xis is peculiar. Instead of the 
axis of vision forming a perpendicular to the surface of the retina at the 
macula, the perpendicular to that surface often passes to the nasal side 
of the nodal point. Hence, in a normal condition of the refracting appara- 
tus, when the plane of the image formed by the crystalline is vertical to 
the a.\is of vision, the plane of the retina forms a greater or smaller angle 
with the image plane. The effect of this anomalous position of the retina 
must be to limit the field of distinct vision in a peculiar manner. It must 
be evident that when the rays, after refraction at the posterior surface of 
the crystalline, are proceeding in the proper course to form an image at 
the macula in a plane which is perpendicular to the visual axis, the image 
can be distinctly and sharply focused only upon a comparatively narrow 
strip of the retina. While the central part of the object is sharply imaged 
at the fovea, the rays which pass to form that part of the image to the 
nasal side of the yellow spot intersect each other in front of the retinal 
surface and form upon the latter circles of diffusion, and those which 
tend to form that portion of the image external to the macula have their 
virtual foci behind the retina, also forming circles of diffusion. While 
it must be admitted that in sclerectasia posticum occasionally the func- 
tional elements of the retina are totally destroyed, generally more or less 
changed, yet in a considerable number of cases where posterior bulging is 
by no means insignificant the rods and cones are tolerably well preserved. 
It cannot therefore be successfully denied that not seldom a certain amount 
of the difference, frequently very great, sometimes unaccountably so, be- 
tween the normal acuity of vision and that which the most careful correc- 
tion by glasses has given, must be due to the condition above stated. The 
amount of this anomaly of refraction has heretofore remained unrecog- 
nizable, and consequently beyond remedy. If its character has been guessed 
at all, the condition has been classed as irregular astigmatism, and there- 
fore irremediable. 

By a little reflection it will be seen that the instrument here reported 
supplies a means of estimating the quantity of this anomaly of refraction, 
and suggests the inclination of the axis of the correcting glass as its 
remedy. 

Another application which may be made of this instrument, and which 
I will only briefly indicate here, is in that it supplies a ready and accurate 
means of measuring the curvature of the cornea in its different meridians, 
and consequently its astigmatism. Hitherto the use of the instrument 
has involved the principle of the formation of images by lenses ; now, on 
the contrary, the principle involved is that of the formation of images by 
reflecting surfaces. In order that rays shall be reflected parallel from a 
convex spherical surface, it is necessary that they go to it as if convergent 
to its principal focus, which is a point behind the surface and half way 



58 Shakespeare, New Ophthalmoscope. [Jan. 

between the latter and the centre of curvature. The eye to be examined 
and the eye of the surgeon are properly placed with relation to the instru- 
ment, when the latter is disposed for examination of the erect imapre. 
The surgeon is to accommodate his eye for distance, or rather parallel 
rays. When the eye is in this state, only parallel rays can be focused upon 
the retina. The holder, carrying as object one of the radiating figures of 
the reduced photograph of Green's tests, is now moved backwards or for- 
wards until the surgeon sees, in the place of the usual foggy reflex from 
the cornea, a distinct and sharp image of the radiating lines. When 
this image is perceived, the rays incident at the surface of the cornea are 
directed to its principal focus. Now the distance of the point of conver- 
gence from the centre of the lens and the distance between the corneal 
surface and the lens are known ; it only remains then to deduct the one 
from the other in order to arrive at the length of the principal focus of 
the curved surface. This being given, the radius of curvature is twice 
that length. By imaging in this manner any particular line of the test- 
figure, the radius of curvature in any particular meridian may be rapidly 
determined. 

Before leaving the consideration of the instrument as an ophthalmo- 
scope one matter may yet be mentioned. This also has a certain relation 
to the formation of images by mirrors. As radiant light after refraction 
by a lens travels as if convergent to or from some point on the axis of 
the radiant bundle and forms there an image of the point of emission, so 
also is it of light reflected by spherical surfaces. When therefore the 
axis of the luminous bundle is coincident with the principal axis of the 
mirror, the image will have its location on the principal axis of the mirror. 
If there be several bundles coming from the several points of an object 
whose centre is upon the principal axis of the ruirror, the centre of the 
image of this object will also be upon the principal axis, and the eye to 
see this image must have its visual axis coincident with the principal axis 
of the mirror. Suppose now that you have two spherical reflecting sur- 
faces placed the one behind the other — that the two surfaces of a lens form 
the two reflecting surfaces. Let the position of your lens be fixed, and an 
object be placed so that the axis ray from its central point shall coincide 
with the principal axis of the front surface; an image of this central point 
will be formed upon the principal axis. In order that the image formed 
by the second surface shall be upon the same line, it is necessary that the 
principal axes of the two surfaces shall exactly coincide with each other 
and with the axial ray proceeding from the central point of the object. 
When, therefore, the eye, placed before these surfaces in a line with the 
axial ray proceeding from the central point of the object, sees the two 
images exactly coincident, it is known that the two surfaces of the lens 
are exactly centred. When, on the contrary, there is a want of coinci- 
dence observed, given the angle subtended by the apparent distance between 



1876.] Shakespeare, Xew Ophthalmoscope. 59 

the centres of the two images, the distance between the reflecting surfaces, 
the index of refraction of the glass and the radius of curvature of the 
anterior surface, the angle which measures the inclination of the axes 
may be calculated. 

It is evident that by applying this principle to the observation of the 
images of the cornea and crystalline lens, we are able in any given case to 
know positively whether the surfaces of the lens are centred with each 
other and with that of the cornea. And when the curvature of the cornea, 
the index of refraction of the aqueous humour, and the distance of the ante- 
rior surface of the crystalline behind the cornea are given, the amount of 
the eccentricity may be determined. Here then is still another of the 
causes of defective vision which may be investigated by the use of this in- 
strument. 

The distance of the pupillary margin of the iris from the anterior sur- 
face of the cornea may be determined when the curvature of the cornea 
and the index of refraction of the aqueous have been j)reviously estimated, 
by focusing upon that part of the iritic membrane an image of the object 
in the holder of the instrument, and then calculating its distance from the 
corneal surface. 

One of the most valuable uses of which this instrument is susceptible is 
that of a camera lucida, for the purpose of accurately sketching the eye- 
ground as it is seen by the ophthalmoscope. The manner of its employ- 
ment for this end may be outlined as follows : The instrument is to be 
arranged as a stationary ophthalmoscope, and the })atient's eye is to be 
placed at k instead of at a. The observer's eye is, as usual, to be placed 
at B. Now, however, instead of the silvered mirror M one of extremely 
thin transparent glass is substituted. The eye of the patient will be illu- 
minated by the rays which pass directly through the transparent glass. 
The rays issuing from the illuminated eye retrace the course taken by them 
in entering, strike the surfaces of the mirror, a part of them pass on through 
and form upon the flame an image of the retina ; but a portion of these 
luminous rays are reflected into the eye of the observer b, as if proceeding 
from the direction of A. The surgeon will, therefore, see the retina of 
the patient projected in the direction of a. If a screen or a piece of 
paper is set up in the direction whence the rays after reflection appear to 
proceed, the eye-ground will appear as if formed upon it, and its details 
may be traced upon the paper with the same ease and accuracy with which 
a microscopic object is drawn by means of the camera. 

Yet another feature of the instrument remains unrecorded. By a small 
attachment in addition to the last-named, it becomes an autopthalmo- 
scope, so that when the curious student desires to look in upon himself and 
to observe from time to time the variations of the circulation in his own 
retina and brain, he is not without the means. This attachment is to be 
fitted when the transparent mirror is in use. It consists of a silvered 



60 Shakespeare, New Ophthalmoscope. [Jan. 

mirror placed in the course of the rays which are reflected from the 
transparent mirror, at right angles to the direction of the latter, and 
at a distance from it equal to that between the pupils of the observer. 
The eye which is to be observed is placed at k, when it will be illumi- 
nated. The luminous rays issuing from it after reflection by the trans- 
parent mirror will proceed to the silvered mirror which has been added, 
and will be reflected by it into the other eye which is to make the obser- 
vation. The observing eye will then perceive the retina of the observed 
eye projected to the point whence the rays appear to emanate after reflec- 
tion by tlie last mirror. 

All the mirrors above mentioned may be substituted by a combination 
of total reflection prisms. 

In the foregoing an effort has been studiously made to avoid as much 
as possible wearying details and mathematical formulae. Indeed, the time 
at our disposal and the limits which we have of necessity set to the extent 
of the present paper have made it impossible that this should be anything 
else than an elementary and preliminary report. It is our intention at 
some later day to place before the professional public the results of some 
investigations, made by means of this instrument upon animals and men, 
when occasion will be taken to refer at some length to the mathematical 
questions which have been suggested above. It may not be amiss to state 
that, as far as my experience with it has gone, the satisfactory working 
of the instrument has demonstrated, in a practical way, the soundness of 
the theory of its construction. Indeed, the rapidity and accuracy with 
which results are reached, and the facility of its use even in the most com- 
plicated cases, are such that I have come to discard entirely, except for 
purposes of comparison, the old and tedious methods of determining ano- 
malies of refraction. 

Simply as an ophthalmoscope its convenience may not equal, under all 
circumstances, those of Loring and Knapp, yet advantages may be claimed 
for it which are possessed by no other instrument with which I am ac- 
quainted. As an optometer, the almost unlimited range of its applica- 
tion and the rapidity and accuracy of its use render it extremely valuable 
for the determination of refraction. As a means for the measurement of 
intraocular objects it is suflScient to say that by its method are avoided some 
of the causes of error which render more or less uncertain the results at- 
tained by other methods, while at the same time animals as easily as men 
are made the subjects of examination. Compared with the devices hereto- 
fore used for the measurement of the corneal curvature, or the direction of 
the axes of the dioptric system, the instrument here considered may lay 
claim to the advantages of simplicity, and facility of use. There being at 
present an urgent demand for pictorial as well as literal descriptions of all 
the living tissues, whether healthy or diseased, the means which are hereby 
supplied of accurately sketching the appearances to be seen in the eye may 



1876.] Thomas, DonI)le Ovariotomy. 61 

uot be witlioiit some value. Finally, the aiitoi)hthalmoscope, wlien it 
becomes a means of noting accurate observations upon the state of the 
circulation as it varies from time to time in one's own eye, is lifted above 
the sphere of a mere optical toy. 

Thus has been described an instrument of simple and compact form, 
designed to accomplish with much expedition and exactness work for the 
performance of which many separate and oftentimes complicated and ex- 
pensive instruments have been devised and employed, and for which it is 
believed the merit of the economy of both time and money may be justly 
claimed.' 

1344 Spruce St., Puiladelpuia. 



Art. IY. — Double Ovariotomy performed for the removal of Solid 
Ovarian Tumours. Transfusion of Milk four days after Operation. 
By T. Gaillard Thomas, M.D., Professor of Obstetrics and Diseases 
of Women and Children in the College of Physicians and Surgeons, 
New York. 

On the ninth of October, 1875, Mrs. S., of Oswego, N. Y., temporarily 
residing in Brooklyn, tet. 30 years, the mother of two children, called upon 
me by the advice of Dr. Chauncey L. Mitchell, of the latter city, and gave 
me the following history of her case. 

Seventeen months ago, up to which time she had been in good health, 
she had been safely delivered of a child. Since that time she had been 
slowly but steadily failing in strength, becoming more and more feeble, 
and within the last six months rapidly emaciating. No cause could be 
found for this constitutional depreciation until last May, when Dr. C. C. 
P. Clark, of Oswego, upon making a careful vaginal examination, dis- 
covered a solid tumour connected with one ovary, not larger than an e^f^. 
Since that time this tumour had gone on steadily increasing in size until 
at the time of her examination by me it was as large as the uterus at the 
sixth and a half or seventh month of pregnancy. 

Besides the marked constitutional depreciation and emaciation which 
had developed during the past six months, no other decided symptoms 
had shown themselves. The menstrual discharge had been absent for 
three months, and some neuralgic pains had existed about the inguinal 
regions and lower part of the abdomen. When asked what her chief suf- 
fering was, the patient would reply that she suffered no absolute pain, but 
that she felt generally wretched and exceedingly feeble. 

Physical examination yielded the following results : the uterus held its 
normal position as to elevation in the pelvis, but was pushed forwards 
towards the symphysis pubis by a round, hard immovable tumour, which 
occupied Douglas's pouch and filled the upper part of the sacral con- 

' The instrument here described is manufactured by J. Zentmajer, 147 South 
Fourth St., Philadelphia. 



62 Thomas, Double Ovariotomy. [Jan. 

cavity. The uterus measured, from os externum to fundus, three inches, 
and upon rotation of the uterine sound, it could be distinctly, though not 
freely, moved without impressing the movement upon the tumour which 
lay behind it. Upon conjoined manipulation the large hard tumour men- 
tioned as occupying the abdominal cavity could be felt. It extended 
above the umbilicus for about three inches, and filled the false pelvis from 
one iliac crest to the other. Its surface was flat and smooth, the tips of 
the fingers could be inserted under its edge, and the tumour could be easily 
moved in every direction, though only to a limited degree. 

I was somewhat puzzled at finding that movements impressed upon the 
abdominal tumour did not proportionately influence that portion felt 
behind the uterus. This fact was fully explained upon opening the ab- 
dominal cavity at a later period. The uterus moved with the abdominal 
tumour, but not nearly as freely as it would have done had this been 
attached to it by sessile attachment or even by a short pedicle. 

Owing to the enfeebled state of the patient, the physical examination 
was not made as thoroughly as it might have been, and was concluded as 
rapidly as was consistent with clearness of diagnosis. 

Upon this visit Mrs. S. showed me a letter from Dr. W. L. Atlee, who 
had examined the case on the 1st of October, 1875, to her physician. Dr. 
Clark, in which he expressed himself in the following words : " I exam- 
ined your excellent patient, Mrs. S., day before yesterday, at Auburn, and 
find a very unique and interesting specimen of disease. I have never felt 
a tumour that more closely resembled a cirrhosis of the liver, and from that 
circumstance, and from her pallid and rather cachectic appearance, I am 
somewhat apprehensive of a malignant basis." He also stated his opinion 
that a resort to operation would be a hazardous one. It was under the 
depressing influences of so grave an opinion from so high an authority 
that she sought my advice. 

The whole history of the case, as well as the physical signs, so closely 
resembled those of two cases of solid ovarian adenoma with which I 
had met, that I ventured to hope that this tumour might partake of that 
nature, and not be true cancer. As the sequel will show, the microsco- 
pists to whom specimens were subsequently submitted differ somewhat as 
to their nature. As all, however, agree in the existence of a decided 
adenomatous element in them, it may not be without interest for the 
general reader to give a sketch of the very meagre literature of this form 
of tumour as it occurs in the ovary. 

In the first volume of Mr. Spencer Wells's work upon Diseases of the 

Ovaries, on page 122, will be found the following description of a tumour 

presented at the Pathological Society : — 

" Mr. Spencer Wells exhibited a specimen of ' adenoma of the ovary,' which 
he said lie thought the most appropriate designation which occurred to him, 
although it might be called fibro-epithelioma, or alveolar adenoid tumour. It 
is identical in structure with the adenoid growths first described in connection 
with the mammary gland, and it was very interesting that it should now be 
found in connection with the ovary. He had not seen a similar growth in the 
ovary before, nor had he found it described by any author. A drawing of Dr. 
Hughes Bennett's of the structure of chronic mammary tumour might have 
been taken from one of the sections shown to the society. The tumour wis 
removed on the third of last September from a sinj^^le lady about fifty years of 



1876.] Thomas, Double Ovariotomy. 63 

ag^e, who recovered perfectly after the operation. It consisted in crreat part of 
an ordinary multilocuhir cyst ; but one larne cyst was fiUed with senii-soiid 
matter, wiiich at first si^ht lool<ed exactly like soft cancer, but after hardening 
in spirit and examining thin sections the true character was made out, and it 
was seen that the surface of the growth was fringed with papilliform villi, its 
substance showing in vertical sections a delicate fibrous stroma forming round 
or oval alveoli. These alveoli are lined with densely grouped epithelial cells, 
forming a continuous zone, which incloses an area loosely packed with cellular 
elements of similar form. On the margins of most sections the contents of the 
alveoli are frequently seen to protrude, like papilht, through ruptured portions 
of the fibrous septa, or the lining zone of the alveolus has become liberated and 
divided so as to assume the appearance of a long cylindrical band or column 
of the epithelial cells. The tumour, therefore, belongs distinctly to the class 
of fibro-epithelial growths, and from the folliculoid character of its alveoli 
would, Mr. Wells thought, be most appropriately classed as adenoma." 

This was in 1862, and Mr. Wells claimed priority in the name. The 
tumour presented was not a solid one, for the patient was twice tapped, 
and on each occasion fourteen pints of fluid were removed. 

Since that period it has become a recognized fact among pathologists 
that a certain degree of adenoid development occurs in every true ovarian 
cystoma. Mr. Wells himself considers, in his recent work upon Diseases 
of the Ovaries, under the head of adenoid tumours, all simple, multiple, 
and proliferous cysts; and Delafield' declares that "in the ovaries most of 
the compound cysts are adenomata, with dilatation of the follicles." It is 
only in exceptional cases that solid adenomatous tumours, with few and 
insignificant follicular dilatations, are met with. I have met with two 
instances of this variety. 

In 1864 a tumour of this character was removed by Mr. Baker Brown, 
presented to the Obstetrical Society of London,'- and referred for special 
examination to Drs. Greenhalgh and Braxton Hicks, who made the follow- 
ing report : — 

" External Aspect. — The tumour is firm, very lobulated, and somewhat kid- 
ney-shaped, the right lobe constituting about one-third, the left two-thirds of 
the whole mass. In its long axis it measures nearly eight inches. The trans- 
verse circumference of the right lobe is about ten inches, that of the left 
about the same. The investing membrane is everywhere closely adherent, 
from which it is separable with difficulty." 

In the right lobe of the tumour were numerous cavities, the largest as large 
as a walnut; in the left a larger one. " On the division of the tumour in its 
long axis the riL'ht lobe cuts like what has been called sarcomatous tissue ; 
the left, being much softer, recedes before the knife, whilst the other was more 
or less cartilaginous." 

"The great mass of the tumour is made up of solid pinkish tissue, the left 
lobe possessing delicate bands of lighter tissue radiating from near its centre." 

After giving the microscopic features of the tumour the committee concludes 
by saying : " We consider, from the general microscopical examinations of the 
above tumour, that it was a specimen of that form of disease recently desig- 
nated adenoma of the ovary." 

Although, as I have just shown, in 1862 and '64 this variety of tumour 
was formally introduced into the list of ovarian tumours by high authority, 

' Post-mortem Examinations and Morbid Anatomy. 
^ Transactions, vol. vi. p. 181. 



64 Thomas, Double Ovariotomy. [Jan. 

it has not been admitted to a recognized position at the hands of syste- 
matic writers. ThusPeaslee,* writing in 1872, says: " It should have been 
stated that adenoma of the ovary has more recently been asserted. But 
since this term is rightly applied only to an hypertrophic development of 
the epithelial element of a gland, the subject needs further investigation." 
He says no more than this upon adenoma. In Atlee's- work, published in 
the same year, no allusion to this form of tumour appears. Barnes is 
equally silent upon the subject, and in the most recent of the works upon 
gynaecology, by Prof Schroeder,^ of Erlangen, it passes likewise without 
mention. The latter author alludes to papilloma, sarcoma, fibroids, and 
carcinoma of the ovary, but nowhere does adenoma receive even a mention. 
"When the large experience of Atlee and Peaslee is borne in mind, with the 
additional fact that Barnes writes in the very city in which Wells first 
drew attention to this form of tumour, it becomes very evident that ova- 
rian adenoma, as a tumour in the main of solid character, has not been 
admitted to a recognized position. 

From this digression I now return to the case which forms the subject 
of this paper. 

As the patient was already greatly enfeebled, and was steadily becoming 
more and more exhausted, I readily assented to her own desire and that 
of her friends, and agreed to perform ovariotomy without much delay. 

On the 14th of October, at 3^ o'clock P. M., I proceeded to operate in 
the presence of Dr. C. C. P. Clark, of Oswego, Drs. Mitchell and Skene, 
of Brooklyn, and Drs. Hunter, Walker, and Jones, of New York. The 
patient having been etherized by Dr. Skene, and placed upon her back 
upon a table, I made an incision through the peritoneum extending from 
a point two inches above the umbilicus to the symphysis pubis. Through 
this the tumour, which was unattached, was removed. The pedicle, con- 
sisting of the right ovarian ligament, Falloi)ian tube, and extension of the 
round ligament, was secured in a clamp, bui upon subsequent examination 
it was found to be so tense that I ligated and returned it to the pelvis. 

Upon examining the uterus it was found to be perfectly normal, but the 
left ovary was as large as a bullock's kidney and lay behind the uterus, 
distending and occupying Douglas's pouch. This was removed like the 
right, and the abdominal incision rapidly closed. 

The whole operation occupied thirty-six minutes. At its conclusion 
the patient was removed to a warm bed, hot bricks put to her feet, the 
room darkened, and perfect quiet enjoined. 

The patient was left under the care of Dr. S. B. Jones, who, on account 
of her very enfeebled condition, remained with her constantly for the next 
five days, and to his watchfulness and care I cannot but feel that the 
subsequent recovery of the patient was in great part due. 

She was kept entirely upon the milk diet, taking this in very small 
amounts, and at intervals of three or four hours, and was quieted by small 
doses of morphia. 

During the next thirty-six hours all went well, the temperature did not 

' Ovarian Tumours. 2 Ovariau Tumours. 

3 Diseases of Female Sexual Organs. — Ziemsgen's Cyclop. 



1876. J Thomas, Double Ovariotomy. 65 

rise above 102^ and the only anxiety which was felt in reference to her 
durinp: this period was created by the fact that she could take very little 
food without voniitinf;, and that her ))ulse, the rate of which was 130 to 
the minute, was exceedintrly small, feel)le, and flickering. On Friday I 
saw her in consultation with Drs. Mitchell and Jones. On Saturday 
morninp:, just thirty-six hours after the operation, I received a telegram 
stating that a rather profuse uterine hemorrhage had come on, and that 
the j)atient had lost ground decidedly in consequence. At ten that morn- 
ing I saw her, and the condition of affairs looked decidedly unpromising 
The jiulse was so rapid and weak that at times it could scarcely be felt, 
and tlie patient began to vomit everything that was put into the stomach, 
even small pellets of ice. The foot of the bedstead was elevated twelve 
inches, cold was applied to the vulva, and the patient kept perfectly (piiet. 
From this time nourishment was given by the rectum alone. 

On the evening of that day I was Ibrced to go to Khinebeck, from 
whence I could not return l)efore the evening of the following day. At 
eleven o'clock that night 1 received a telegram from Dr. Jones, stating 
that the uterine hemorrhage had recurred so violently that with the assent 
of Dr. Mitchell he had used a vaginal tampon, and that the patient was 
siid<ing so rapidly that she would die before morning. Reaching home 
late on Sunday night I found that death had not occurred, and early on 
Monday morning I went to Brooklyn to see her. 

On this visit I found everything looking very badly. Both stomach 
and rectum rejected all nourishment; the temperature was only 102°, 
but the pulse was small, flickering, and beating at 140 to the minute. 
It was agreed that very small amounts of fluid food should be cautiously 
tried by stoHiach and rectum, and, as the patient appeared to be dying 
from sheer exhaustion, the result of previous enfeeblement by the disease, 
and more recent starvation and loss of blood, that, in case Drs. Mitchell 
and Jones sliould towards iiigiit feel convinced that death would occur, I 
should be summoned to perform transfusion. 

At ^ix that evening (.Nlonday, four days after operation), I received a 
telegram urging my immediate attendance on Mrs. S., who appeared to 
be rai)idly sinking. When 1 saw her I found her bathed in cold sweat, 
with a temperature of 10 P, a pulse of 150, and a facies expressive of 
approaching dissolution. It was decided at once to try the effect of trans- 
fusion. 

Three experiments with the transfusion of blood rendered me very 
averse to the employment of this fluid, and with the consent of my col- 
leagues I decided to employ instead perfectly pure, fresh milk. This 
idea suggested itself to my mind from the recollection of some cases in 
which it was employed twenty years ago by Dr. Edward M. Hodder, 
of Toronto, Canada. In 1850 Dr. Hodder injected this fluid into the 
veins of three patients moribund from Asiatic cholera, which was at 
that time epidemic in Canada. In a comraunication from him he informs 
me that he injected as much as fourteen ounces at one sitting; that no 
alarming symptoms occurred ; that good results manifested themselves 
from the first; and that two recoveries had taken place in patients who 
appeared moribund when the operation was resorted to. He was encour- 
aged to try the method from the fact that Donne had injected milk into 
No. (^Xl.I.— Jan. 187(>. 5 



66 Thomas, Double Ovariotomy. [Jan. 

tlie veins of dogs and rabl)its without injury to them. Since the cases 
reported by Dr. Hodder, I know of no one who has repeated this experi- 
ment in the liuman being until a year ago, when Dr. Joseph W. Howe, of 
this city, injected si.x ounces of warm goat's milk into the cephalic vein of 
a patient suffering from tubercular disease, and who appeared to be dying 
from starvation in consequence of an inability to retain nutritious material 
by either stomach or rectum. Dr. Howe declares that — 

"When nearly two ounces had been thrown into the circulation, he com- 
plained of pain in the head and vertigo. The eyes twitched from side to 
side (nystagmus), and he said he could not see. The same symptoms 
recurred when the next ounce was thrown in, and ceased when the injection 
was suspended. The third repetition of the same quantity produced pain 
in the chest and dyspnoea, and no brain symptoms. His pulse seemed to 
be fuller after the operation, and he said he felt better Death took place 
four days afterwards. A post-mortem examination showed that there 
were no clots in the veins of the arm or in the lungs. The brain was 
normal. I don't think the operation improved his condition, notwith- 
standing the fact that the [latient himself and the house surgeon thought it 
did." 

Having decided to inject milk into the veins of my patient, a young and 
healthy cow was driven into the yard, a pitcher with gauze tied over its 
top was placed in a bucket of warm water, the vein was exposed and the 
cow milked at the moment the fluid was needed. By means of the very per- 
fect and safe transfusion apparatus of M. Colin of Paris, I slowly injected 
eight and a half ounces into the median basilic vein. The first effect 
which evidenced itself did so after about three ounces had been injected. 
Then the pulse became so rapid and weak that Dr. Mitchell, who kept it 
under liis finger during the operation, could scarcely detect it. The patient 
declared that she felt as if her head would burst, and seemed greatly over- 
come. I went on slowly, however, transfusing the fluid until the amount 
mentioned had been reached ; she was then left perfectly quiet. 

In an hour from this time she had a decided rigor, the pulse was found 
beating between 150 and 160 to the minute, and the temperature rose to 
104°. This high rate of temperature, however, soon passed off, and 
towards midnight the patient fell into a quiet sleep, from which she did 
not awake until morning. 

I saw her about ten the next day, when Drs. Mitchell and Jones gave 
me a very encouraging account of her. As I entered her room she said in 
a feeble voice, " I feel that I am going to get well." This I was particu- 
larly glad to hear, as during the previous day she had given up all ho[)e 
and was utterly despondent. The pulse was beating at 116 to the minute, 
the temperature was 99;^°, the tendency to sweating had disappeared, and 
the facies had much improved. 

During the day very small amounts of iced milk and lime-water were 
given by the mouth and retained. From this time onwards it would be 
needless to mark the daily changes which occurred. The patient steadily 
progressed to complete recovery, and on the twenty-first day after the ope- 
ration, upon a visit made by Dr. Jones, she walked down stairs to meet 
him. The notes taken by him on this occasion declare that " the appetite 
is excellent, the patient growing stout, sleeping well, and gaining every 
day." Six weeks have now elapsed since the operation, and the patient 
is entirely well. 



187fi.] Thomas, Doiilik' Ovnriotomy. 67 

The {rciieral appcarinice of the tumours is as follows : The lartjer re- 
sembles closely ill uspect a eirrhosed liver. It measures iu its longer cir- 
cumference 10 inches; in its shorter IG^ inches ; and weij^hs 4^ pounds. 
The smaller tumour resembles a larj^e fatty kidney ; measures in its long 
circumference 12 inches ; in its shorter Ih inches ; and weighs H pounds. 

Upon section a nnml)er of cysts were found in the larger tumour about 
the size of a chestnut, and filled with colloid material. In the smaller 
tumour no cysts appear except upon the circumference, where a few small 
ones, the largest about the size of a marble, exist. 

Four gentlemen have examined these growths by the microscope, and 
as their reports differ somewhat I give them in their own words. They 
are presented in the order in which they were handed in.' 

Report of Dr. E. G. Janeway: — 

"The microscopic examination of the tumour of ovary shows — 

"1st. More, at the periphery, Hbroid tissue with normal or some excess 
of cellular elements. In some spots I noticed an accumulation of lym- 
phoid cells in this. 

" 2d. More central, sarcoma tissue, numbers of gpindle cells arranged in 
groups with but little int«rme liate tissue in parts. In some places the 
section had divided these transversely, giving the appearance of groups of 
round cells. 

"3d. Rounded spaces lined by epithelium, mostly of polygonal character, 
in some approaching a little to the cylindrical. 

"4th. Occasionally smooth muscular fibre cells. 

" The name properly would be sarcoma. I think that in part these fol- 
licular spaces are of new formation, and that perhaps adeno-sarcoma 
would be a better name. 

"Here and there I ob.served spaces from which a j)art of the fluid noticed 
on section escaped. These showed little spaces between the cells which 
assumed more of a stellate character." 

Report of Dr F. H. Chapman: — 

"The tumour is ' adenoid.' 

"Thin sections of the alcohol-preserved preparation presented simply a 
dense filjrous tissue ; but treatment by water, and afterwards by acetic acid, 
enabled me to obtain beautifully reticulated connective tissue, the meshes 
of which were filled with colloid globules, oil-globules, and granulations. 
No cells could be found; cells in the strict pathological sense, although 
the ' nuclei' and 'cells' of Spencer Wells were abundant. 

"In order to verify the diagnosis, other methods were adopted. With 
caustic potash the connective tissue was dissolved, leaving as a residue the 
globules of different kinds which are not readily acted upon by this agent. 
Thin sections were also tinged with carmine and coloured in gold, the 
former of which methods produced fine specimens of connective tissue 
reticulation, and the latter, by colouring the globules and so-called cells, 
enabled me to judge more accurately of the proportion of globules to the 
tissue. * 

"Vessels were not numerous. The nerves were not studied, as for this 
portion of the structure fresh specimens are necessary." 

Report of Dr. J. Adler: — 

• These tumours are preserved in alcohol, and I shall be happy to forward .sec- 
tions of thein to any inicroscopi.~t who would like to examine them. 



68 Thomas, Double Ovariotomy. [Jan. 

"The portion of tumour presented for examination appeared as a wliitisli, 
tolerably firm substance of apparently fibrous structure, and containing a 
number of small cysts of about the size of a pin's head. Most of these 
little cysts contained clear colloid matter. But very little material could 
be scraped away with a knife, and this consisted mainly of small epithe- 
lioid cells. These transparent sections examined under the microscope 
showed somewhat different structure in different iocaliti'es of the tumour. 

"One set of sections showed the following : — 

"A stroma consisting of fibrous tissue mostly wavy, often denser and 
firmer, containing but few puriform or small round cells. In this stroma 
are imbedded follicles, evidently Graafian vesicles, with all peculiarities of 
structure with this exception, that in many the ovum cannot be detected, 
but the cavity is filled up by a mass of proliferating epithelial cells. We 
find further, follicular cysts retaining mostly the lining of short cylindrical 
epithelium and filled with colloid. And lastly, irregular epithelial masses 
of considerable size, involving usually a number of follicles from whicli 
they seem to originate; frequently these masses are strikingly similar to 
the 'epithelial-tubes' (Epithel-SchlJinche) of Pfliiger and Waldeyer. A 
second set of sections representing the main portion of the piece of tumour 
under examination showed the following : Fibrous tissue, mostly firm and 
dense, containing but few cells, arranged so as to interlace in various 
directions and form an extensive network. The bands of fibrous tissue are 
sometimes very broad, sometimes but very thin and delicate. The meshes 
thus formed vary in size, being sometimes hardly perceptible between the 
masses of fibrous tissue, as a rule, however, tolerably large, and through a 
large tract of tumour nearly equal in size, thus jiresenting an appearance 
of great regularity. Tliese spaces between the bands of fibrous tissue are 
filled up with epithelioid cells, showing a large nucleus and an irregular 
usually flat protoplasmatic body. The size of tliese cells varies somewhat, 
on the average they do not exceed the size of the epithelium of Graafian 
vesicles. These latter occur also in this set of sections usually filled up 
with epithelium. 

"A third set of sections from but one or two spots of the piece under 
examination seem to consist, at first view, mainly of fibrous matter in 
which a higher power shows numbers of spindle-shaped cells arranged in 
bands, and here and there particles of large granulated round cells. Here, 
too, a closer examination detects, everywhere, filling up the interstices 
between the fibrous matter, epithelioid cells similar to those described 
al)ove. Besides tliese three sets of sections a number of others can be ol)- 
tained which exhibit combinations of all the structures described above. 
The tumour is moderately vascularized. Bloodvessels show no abnormi- 
ties. 

"The first set of sections described ranges, as regards diagnosis, undoubt- 
edly under the head of Adenoma in the sense useu by modern authors and 
especially Klebs (Handbuch der Patholog. Analumie, p. 796). Taking 
its origin from this adenomatous growth, the bulk of the tumour seems 
made up, as shown by second set of sections, of tissues m(*derately carcino- 
matous. This form of carcinoma, originating in adenoma of ovary, has 
often been de.-cribed (Klebs, loc. cit. p. 8U9, as fibrous carcinoma ; Yirchow, 
Die KraukhaJ'ten GescJnvilhke, vol. ii. 370). A certain amount of 
sarcomatous tissue seems to enter into the composition of the tumour as 
shown b} the last set of sections. The sarcomatous tissue has evidently 
dovch^ped from the fibrous stroma, and as, nearly always, in sarcoma of 



1876.] Wallace, Mct-lianioal Treatment of Fkxions of Uterus. (19 

ovary, def^eii crates into carcinoma (sarcoma carcinomatosa, Yirchow, loc. 
cit.), altoffether the tumour may be classified as adenoma carcinomatosa." 

Report of Dr. Francis Delafield : — 

"Specimens were examined from both the large and small tumours. In 
both the structure is essentially the same. 

"Tiie tumours are conjoint in their structure. AVe can distinguish — 

"1. Large rounded and tubular follicles lined with epithelium. Some 
of them are dilated so as to form cysts. They look like the follicles found 
in adenomata of the ovaries. 

"2. Long rows of polygonal nucleated cells looking like true cancer. 

"3. A reticulated arrangement of connective tissue, the spaces large and 
small. The small spaces containing cells, the larger colloid matter. These 
larger spaces do not resemble the dilated follicles spoken of under (1), 
although these also contain colloid matter. This stimulated tissue 
reseml)les exactly colloid cancer. 

"4. The stroma in ordinary fil)rillated connective tissue, in some places 
infiltrated with round cells. 

"Classing the tumour according to its more important elements, I should 
call it a carcinoma, i)artly simple, partly colloid complicated by the growth 
of glandular follicles such as are seen in ordinary ovarian adenomata." 



Art. V. — A Neiv Mechanical Treatment of Irreducible Flexions of 
the Uterus. By Ellerslie Wallace, M.D., Professor of Obstetrics 
and Diseases of Women and Children in Jefferson Medical College, 
Philadelphia. 

I DESIRE to call the attention of the profession to a plan of treatment 
of what is often called " irreducible flexion" of the uterus, with the hope 
that they will patiently and carefully make trial of the same, with the view 
of proving the accuracy or the error of the opinions which I believe, from 
experience, that I am warranted in holding. 

Between eight and nine years ago, I had a patient whose uterus was 
somewhat enlarged, badly retroflexed, and while devoid of any evidence of 
inflammation, yet was somewhat, though hut slightly, tender to the touch. 
It bore a critical examination, both with finger and with sound, well, and 
with no bad result. But the woman was suffering from dysmenorrhuea, 
from pressure on the rectum, and other ailments which such cases some- 
times present, and which are so familiar to observers, that I need not 
prolong this paper by describing them. 

Having utterly failed for a time in my attempts to relieve her, and 
being greatly interested in her case, I thought of the plan which I shall 
describe below, and so made my first venture. 

The result was a perfect cure. I have often, since that time, resorted 
to the same plan, and with such good results, that in the last few years I 
have advised the treatment in my lectures to the classes at Jefferson 



10 Wallace, Mechanical Treatment of Flexions of Uterus. [Jan. 

Medical College. I suggest as follows : Take a choice elastic sponge, 
well cleaned, but not bleached (for bleaching impairs the elasticity); cut 
out of it a piece either perfectly straight, or, preferably for retroversions, 
slightly curved, according to the normal curvature of the healthy uterus. 
Wrap it, etc., as in the making of an ordinary tent. Withdraw the needle, 
and bend the yet moist tent to correspond as nearly as may be with the 
shape (we will suppose a retroflexion which has been measured by the 
sound) of the disordered womb. Secure the tent, thus bent, by fixing it 
on a board or stout pasteboard, witii pins along its sides. When it is 
dry, finish it as an ordinary tent should be finished. Make other tents in 
the same way of lesser curvature, and of somewhat greater diameter. If 
the pieces of sponge have been cut out forward-curved, as I suggest 
above, they should be bent backward carefully. If they are straight, which 
is better for anteflexions, they are simply to be bent on their longitudinal 
axes. 

I deem it prudent not to begin the treatment until three days have 
passed after the cessation of a menstruation, nor to resort to it at all for 
three days prior to a menstrual epoch. So that there may be but about 
sixteen or eighteen days, during each lunar montii, in which the treat- 
ment should be used. Having the bowels emptied, if not naturally then 
by an enema, in the early morning, I insert a curved tent of small diameter 
into the uterus, up to the fundus, and support it in place by the usual 
vaginal tampon, I keep the woman quiet in bed, direct a light diet, and 
pay her a second visit in ten or twelve hours. If she be comfortable, I 
generally do not remove the tent for ten or twelve hours more. So, in 
from twenty to twenty-four hours from the time of the insertion, I with- 
draw the tent, and if there be no undue soreness and no constitutional dis- 
turbance, I immediately re{)lace it with one of less curvature, but of some- 
what larger diameter. I allow this one to remain from ten to twenty- 
four hours, if all goes on well. If the second tent have produced no evil 
symptoms, local or general, I now insert a third, still less curved, and a 
little greater in diameter, provided thai the ivomb has not been ivell erected 
by thin time ; for I have found, in a few instances, that two tents, used as 
described, have sufficed to entirely rectify the shape of the organ. I have 
feared to use more than three on any one occasion ; perhaps I have been 
uselessly timid, but I prefer to avoid all possible risk of metritis. Some, 
but very few, of the wombs which I have dealt with, have been so singu- 
larly insensitive, that I have endeavoured to hasten the process by changing 
the tents at ten, twelve, or fifteen hours' interval. The expansion of the 
tents will, to a limited degree, tend to the effacing of the curvature of the 
womb, but the tendency of the elastic, bent spouge to resume its di7rct or 
its slightly forivard-curved shape, will do much to restore the organ to 
its normal shape ; far more, indeed, than I at first supposed probable. 

I keep the patient quiet, in her bed, for at least two days after the re- 



187G.] Wai-i.ack, Mrrliiiiiiciil Treatment of Flexions of Uterus. 71 

moval of the la^l lent ; then I i)ermit lier to rise and to move alK)ut 
gently, cantioninjf her ajiainst strong muscular exertion of any kind, and 
especially against the usual and ])ernicious mode of dress which so gene- 
rally obtains among women in all classes of society. I insist upon the 
dress being loose at the waist, and I direct the skirts, all of them, to be 
l»ro))erly supported from the shoulders, that no weight whatever may be 
thrown upon the abdomen. 

I judge it prudent to deal most gently, and init slowly, with long stand- 
ing cases, in which we may reasonably suppose the tissues to bo more 
resistant, and therefore to require more time for their management, than 
cases of comparatively recent origin. A too rapid compulsory change of 
sha))e, in old cases, seems to me to be likely to so strain the tissues as to 
provoke inflammatory action. In those instances in which the first trial 
has proved but partly efiectual, I make a second attempt in four, five, or 
six days. Nor am I discouraged by being obliged to subject the patient 
to a second or third treatment, or more. Some wombs will, after being 
brought up, bend again quickly and obstinately, and will re(]uire a series 
of well-conducted attacks. 

When the uterus is well rectified in shape, it will not do to leave it to 
its own devices. It should be examined at — say — three days' interval, for 
some few weeks, that, if the flexion incline to recur — of which there is 
always possibility or probability — the treatment may be at once resorted 
to again, and here a straight tent or a forward-curved one, which has 
been bent back to a straight line, may probably be inserted, while the 
deviation is yet but beginning, for the womb is generally pliable enough 
to accept such an one, especially if its diameter be small. 

I suggest that tents of small diameter should be used at first, and that 
their size should be cautiously increased ; for I feel well assured that some- 
times the evils charged to sponge tents are really due to their undue mag- 
nitude, and the consequent too violent and forcible dilatation. We may 
be a little more bold, after one experiment, if the action of the remedy at 
the first trial has been well sustained by the womb. 

Some of our patients who are affected with flexions, and whose wombs 
are at the same time in some other pathological conditions, will, upon 
relief being given to these additional and, perhaj)S, pre-existent disorders, 
experience so much comfort — will, in fact, feel so nearly well — that they 
will decline further treatment. Yet we all meet with cases in which the 
flexion exists associated with but little hypertrophy, so little as to escape 
the notice of any but a very accurate observer, and where the nervous and 
vascular conditions are but very little, if at all perceptibly, disturbed; yet 
the women will suffer from dysmenorrhoea, from pressure on the rectum 
or the Ijladder, from dragging of the bladder, from depression of the woml) 
consequent upon the weight of the intestines on its anterior or posterior 
face, etc. 



72 Wallace, Mechanical Treatment of Flexions of Uterus. [Jan. 

Such are the cases in which I find the treatment, which I have described, 
to be very effective, often curing them perfectly. Of course, hypertrophy, 
as a coni]ilication, does not forbid tbe treatment. It is, in fact, an addi- 
tional reason for the use of the tents. The influence which they often 
exert as reducers of hypertrophy — first pointed out, I believe, by Sims, and 
now so largely known through the circulation of liis work on Uterine 
Surgery — is of great advantage in the hypertrophy which so very often 
accompanies flexion. But I would hero caution the comparatively inex- 
perienced practitioner, who may resort to the plan which I propose, to be 
very careful that the womb is in condition to bear the insertion, and the 
action of this elevator and dilator. For, if the womb be inflamed, or 
be super-sensitive to any material degree, the tent may be expected to de- 
velop metritis, with its possible extensions of inflammation to the pelvic 
tissues, or to the peritoneum, or both, even more than in the case of a 
mere dilating tent. Moreover, the tent, and the vaginal tampon used for 
its support and retention, should have strings attached to them, that, if 
untoward symptoms arise between the physician's visits, both tampon and 
tent may be withdrawn by the patient or by her attendant. These symp- 
toms should be explained to the woman or her attendants, that they may 
be able to act advisedly and prudently, and so to remove the cause of 
what might be even a fatal issue. 

While I have had some excellent successes with the above plan of man- 
agement of flexions of the uterus, yet, in spite of my care, I have had two 
instances of metro-peritonitis consequent on my procedure. In the first 
case the retroflexed womb rose handsomely in twenty-four hours, but in 
the succeeding day, during my absence, violent pain set in, and when I 
was able to see my patient, and to withdraw the tent, there was unmis- 
takable evidence that the womb was bound down, near the fundus, by old 
adhesions. True, it was but little confined, but that little was enough to 
resist the full lifting power of the tent, and the two opposing forces ex- 
erted on the womb, developed a fearful metritis, which rapidly ran on to 
peritonitis, from which she made a tedious though a i)erfect recovery. 
Her womb was hypertrophied largely, though devoid of any hypertesthetic 
or hyperiemic condition when I ap})lied the first tent. To my surprise 
and pleasure, I have, since her recovery, found that the uterus has not 
fallen back quite (\civi\\ to its original position, and that, in spite of the in- 
flammatory attack, its hypertrophy has been lessened — perhaps due to the 
impression of the tent, as pointed out by Sims. She has been far more 
comfortable in all respects, local, constitutional, and sympathetic, since 
her recovery (seven years) than she had been for the eight years preceding 
my venture. The second case was one of retroflexion and hypertrophy. 
On the second day metritis began, followed by peritonitis on the following 
day. The attack was grave, but not really dangerous. The uterus was, 
in consequence of the peritonitis, agglutinated in its false j)osition, and 



1876.] Wallace, .Meclmiiical 'ri-eutinenl of Flexions of Uterus. 73 

boiiiul to its improper shape. I am uiial)le to say positively wlietlier the 
hypertrophy was ullimately diminished or not ; but I do not think that 
it was, judtjinf^ from one careful examination. Yet she had been better 
in all respects, by far, than prior to the attempt at reduction ! Could it 
be possible that the womb, being fused fast, ceased to give distress because 
its mobility icas arrested? 

I have used a Hodge pessary, a few times, to support the womb when I 
had restored it wliolly or partly from its mal-position and mal-shape, in 
cases of retroflexion. Where the organ was partly straightened, the 
pessary did no good; the womb bent down again and hurt itself on the 
upper bar of the pessary. Yet 1 think that the pessary ought to tend to 
prevent, or at least to check and to delay the recurrence of tlie bend, by 
holding the body of the uterus somewhat forward, and, moreover, by 
giving opportunity for the intestines to fall behind the womb while it is 
held forward ; and I will not fail to try it again, as opportunity may 
offer. 

In the instances in which the womb was well erected, I think, but I 
cannot say certainly, that I saw benefit produced by the instrument ; some 
wombs will remain in proper shape when restored once, or more than 
once, and some will go back persistently. This adjuvant treatment 
demands further trial and investigation. 

Having found, occasionally, an obstinate uterus, that responded bnt 
little (I have never seen one that did not respond at all) to the power of 
the tent, I have tried what may, or may not, prove to be an improvement 
in the making of sponge tents for the purpose described in this paper. 
It is to wrap the tent, not on a needle or awl, but on a piece of watch 
spring, either straight or slightly forward-curved ; which spring is left in 
the sponge, and all dried together, after being bent as advised near the be- 
ginning of this article. I have used very delicate spriiigs so far, but if I 
should find them of benefit, I will try springs of somewhat greater 
strength. 

In one case, the sponge seemed to have been defective near its point, 
and the spring was peeping through the softened and dilated mass when 
I withdrew it. To prevent the possibility of such an accident, my friend, 
Dr. Stanley Smith, made some beautiful tents for me, in which he had 
tied the foricard end of the spring in the sponge by a subcutaneous^ 
ligature. In two cases only, have I used these modified (for I will not yet 
call them improved) tents ; they answered very well in one case, and in the 
other the patient removed before the test was complete. My object, as 
will be seen at a glance, was to increase the lifting power of the tent, 
without enlarging its diameter. 

' Tliougli an inact urate expression, I believe tliat it will convey the idea, with- 
out the need of further explanation. 



T4 Wallace, Mechanical Treatment of Flexions of Uterus. [Jan. 

I do not like conoidal tents ; I prefer them made exactly of the same 
diameter in the entire length, with only a little tajiering close to the 
point. They are decidedly more effective than the cones. 

If these modified tents should prove advantageous, I will report on the 
subject in future. I have kept no written record of my cases, as above 
described in general terms. This communication would, I know, be more 
satisfactory, if I bad such record to report from in detail, but, simply, I 
have it not, and can draw only on my memory. 

P. S. — November 9. Some days before the above was written, a woman, 
married and a mother, presented lierself at one of my clinics at Jefferson 
Medical College. She had hypertrophy, anteflexion, and anteversion ; 
she suffered from severe dysmenorrhoea, and from great irritability of the 
bladder, with difficulty in voiding urine. She said that she was obliged 
to empty the bladder very many times daily, and some five or six times 
every night; and that whenever she attemi)ted to evacuate the bladder, 
she was compelled to strain, and bear down for two or three minutes 
before she could pass any urine at all ; and that this effort was succeeded 
by distressing pain, which lasted for many minutes, rendering her utterly 
wretched. There was no apparent inflammation of her womb, and the 
sensitiveness was but little more than normal. My chief clinical assistant. 
Dr. C. McClelland, visited her at her home, and used three curved tents 
for her relief. He allowed each tent to remain in place for twenty hours. 
The first and second tents contained watch spring, the third was plain. 
On the fourth day the womb was normal in shape, though yet hypertro- 
phied. Two weeks from his last visit she menstruated without i)ain, and 
when I saw her, one week after this menstruation, she said that she had 
been free from all distress in, and after, urination, ever since the last tent 
was removed. A few days after, some uneasiness returned, and I found 
the womb tending to anteflex again ; Dr. McClelland used three tents, as 
before. To-day, Nov. 9th, the womb is correct in shape, but she has a 
sense of weight and fulness in the pelvis, with slight prolapse; due, I 
consider, to the still remaining, though diminished, hypertropliy. I have 
directed leeches to be applied over the external abdominal ring, and along 
the inguinal canal. 

2_4th. She was seen to-day. Her uterus is absolutely correct a.«< to 
shape, but slightly prolapsed from the still existing hypertrophy. The 
leeches have relieved the weight and fulness. Sickness of her husband 
stops our treatment for the present, as she is obliged to attend on him 
day and night. She declares that she is "feeling like another woman, so 
great is the improvement." 

Nov. 20th, Dr. McClelland has furnished me with notes of a few cases 

treated by him, which I sulyoin : — 

Case I. — Seen, February 16, 1874. A woman married for some years; 
childless. Had extreme retroflexion, with dysmenorrhcBa, and suffered 
constantly with local and symi)atlietic ailments. Two tents, used twice, 
at interval of one week. The womb was straightened, and the dysmenor- 
rhoea was entirely relieved for two months, when she passed from observa- 
tion. Dr. McClelland hus just learned from one of her friends, that her 
health is now good, and that it has l)een so since he last saw her. 

Case II. — Seen, June 29, 1874. A woman married and childless. 



187(5.] 'Wallace, MoclmniLMl Treatment of Flexions of Uterus 75 

Had retroflexion and dysmenorrlicea. Ajipetite defeetive; wiiole system 
enfeeliled. Two tents used. Uterus straightened and dysmencjrriioja 
cured. After two months, she also passed away from observation, and 
has not Ijcen heard from since. 

Case III, — Seen, July fi, 1874. An unmarried woman. Had antero- 
lateral flexion. Three applications of tents: 1st, two tents used; 2d, 
three ; and 3d, one only. The od tent of the second application, remained 
in place forty-eight hours, witli no bad result. She would not keep quiet, 
but went about her house with the tents in the woml). The uterus rose, 
but presently fell again. No iniprovement. Useless to continue treat- 
ment, because of her disol)edience. 

Case IV. — Seen, August 17, 1874. A woman married and childless. 
Had inflammation, ulceration, hypertrophy, and retroflexion, with a for- 
midable train of local, functional, and sympathetic symptoms. She was 
extremely feeble, and resembled, in general expression, a person laljouring 
under phthisis. After the ulceration and inflammation were cured, tents 
were used, and the woml) was straightened, and the distressing symptoms 
passed away; her general appearance and her health were very much im- 
proved. Some hypertrophy still existed, but the womb remained straight 
to August, 1875, wlien family circumstances compelled cessation of treat- 
ment, up to this date, November 20th. 

Case V. — Seen, September 2, 1874. A married woman ; had a mis- 
carriage in June. Now had a very bad retroflexion, with dysmeiiorrhcea, 
and concomitant, severe, local, functional, and sympathetic symptoms, and 
was very thin and very feeble. Two tents used twice, at two weeks' in- 
terval. These sufficed to straighten the uterus; it remained straight, and 
she regained flesh and strength. She became pregnant toward the middle 
of November, 1874, and was confined August 19, 1875. Is now well. 

Case VI. — Seen in July, 1875. A woman married and childless. Had 
anteflexion, with dysmenorrhosa, and frequent and painful micturition ; 
obliged to j)ass water about once an hour, day and niglit. Two watch- 
spring tents used. The womb almost straightened by them, with entire 
cure of dysmeiiorrhcea for two periods, and very great relief to bladder. 
She died, suddenly, from cholera morbus, while ai)sent from the city, before 
a third menstrual period. 

Case VII. — Seen, October 1, 1875. A married woman; miscaiTied at 
three months, about three years ago, since which she has not been preg- 
nant. She dates her disorder from the time of the miscarriage. Had 
retroflexion with dysmenorrhoea. By the use of one watch-spring tent, 
and one plain tent, the uterus is straightened. Has menstruated twice, 
painlessly, since the tents were used. 

Case VIII. — Seen November G, 1875. Had antero-lateral twist. She 
had been treated successfully for inflammation and ulceration of cervix, and 
on November 6, tents were used to rectify the shape. Three tents were 
necessary, and at this date, November 20, she is comfortable and the 
womb retains its proper shape. 

I lay stress on the qualiti/ of the tents. Many of those sold are valueless, 
wanting elasticity and expansive power. The only really elegant tents 
are those which I have had made specially, and to order, from the choicest 
sponge, or those which have been given to me by Dr. McClelland and 
Dr. Stanley Smith, and which have been made by them. In one of my 
cases, I observed that after the use of the tents, on three different occa- 



7G Rodman, Miasmatic Infections Pneumonia. [Jan. 

sions, there was not only marked improvement in the strengtii, and embon- 
point, and active vigour of the woman, but that a very marked increase iu 
the sexual appetite occurred, which still remains. Dr. McClelland tells 
me that in one of his cases the same result was noticed. 



Art. YI. — Endemic of Pythogenic or Miastnatic- Infections Pneu- 
monia, with Illustrative Cases. By W. B. Rodman, M.D., of Frank- 
fort, Ky. 

There occurred during the year 1874, in the Kentucky State Prison, 
seventy-five cases of pneumonia. These cases I made the basis of a report 
which was published in the Xew York Med. Record iov March 13, 1875. 
They very closely resemble pneumonia as ordinarily seen in private prac- 
tice, both as regards symptoms and pathological changes, except in degree 
of severity. The symptoms were decidedly intensified, and post-mortem 
examination revealed much more involvement of lung tissue than obtains 
in ordinary pneumonia. The causes were the manufacturing of hemp 
(.<lig7}tly), the broken-duwn condition of the men, and principally the de- 
ficient ventilation of the cells and cell-house. The mortality was 8 per 
cent. The treatment was that which I employ in private practice, viz., 
carb. ammonia, quinia, stimulants, and nourishing diet, with the applica- 
tion of turpentine stupes followed by poultices of flaxseed. From Janu- 
ary 1st, 1875, to February I24th, sixteen cases of the ordinary pneumonia 
had occurred ; of these, one died on January 23d, after an illness of two 
days. About the la.-^t week of February it was evident that the type of 
pneumonia had radically changed, and a form which I have designated as 
pythogenic or miasmatic-infectious developed itself. I think it best, just 
here, to explain exactly what I mean by miasmatic-infectious. To those 
who have read Prof. Liebermeister's introduction " Infectious Diseases," 
in vol. 1st Ziemssen's CyclopiEdia, no explanation is necessary, for I use 
the term exactly as he does. And all through this article I will use the 
words infection, contagion, etc., as he understands them. That is, an 
infectious disease is one in which tiie body is infected by specific poisons, 
which can rejiroduce themselves. Infectious diseases are subdivided into 
miasmatic, contagious, and contagious-miasmatic. In miasmatic the 
specific poison is developed outside the body ; in contagious the })oison is 
developed in the body, and then given by contact, mediate or immediate, 
to a non-infected body. Ordinary intermittent fever is an example of the 
miasmatic, small[)ox of the contagious, both of these being infectious. 
Typhoid fever is an example of the miasmatic-contagious. In this disease 
the specific poison undergoes a partial development in the infected body. 



1870.] Rodman, Miusniatic Iiifi-c'lioiis Pneumoiiiii. 77 

but this poison cnniiot infect a sccoiul l)0(ly until it has ])assefl from the 
first, and untlerf;one a further development as a miasm, and then if taken 
into a healthy body it may produce the disease. This much merely to 
explain my meaning when I use the words contagion and infection. 

The form of pneumonia which I am about to describe, I Ijelieve to be 
identical with "sewer gas" or "pythogenic pneumonia." This form we 
find mentioned, only recently, in the various medical journals, and I believe 
no te.xt-book gives us any definite idea of it. Prof. G. B. AVood describes, 
under the head of bilious pneumonia, a disease of ordinary malarial com- 
jilications, such a disea.se as would be, without the pneumonia, an attack, 
simply, of remittent or intermittent fever. Prof. Flint, when speaking of 
a fatal form of pneumonia, which prevails in the Southern and South- 
western States, refers to the same character of cases. Niemeyer vaguely 
hints at this peculiar form of pneumonia, and Roberts mentions as one of 
the causes croioding and imjjerfect ventilation. This miasmatic-infectious 
pneumonia diflfers essentially from that form of the disease which is caused 
l)y "taking cold," or that which comes on as a complication or sequela of 
smallpox, measles, typhus or typhoid fever, or is produced by any atmos- 
pheric or telluric changes. This form I believe to be caused by foul ema- 
nations from sewers, privies, or drains, and also by men being crowded 
together in sleeping apartments insufficient in size and imperfectly venti- 
lated- I will now proceed to give my reasons for taking the view I have 
announced : — 

Last fall and winter, there was an unusual prevalence of ordinary pneu- 
monia over this whole section of country. I had more cases in private 
practice than ever before in the same length of time. During this epi- 
demic, the prison was not spared. Whether to attribute this unusual 
amount of pneumonia to an excessively cold winter, or to some myste- 
rious epidemic influence, I know not. Certain it is that there was no 
extraordinary number of cases of zymotic diseases of any kind in this 
vicinity. The cases which I then saw differed but little from ordinary 
pneumonia. After a time this " influence" ceased, and it was rare that 
I heard of a case of pneumonia in my own, or the practice of any of my 
friends. At the time mentioned, February ■24th, cases of this fearfully 
fatal pneumonia began to pour into the prison hospital, and I set myself 
to work to find out what this fearful poison could be. The cell-house is 
olO feet long, 43 feet wide, 75 feet high, and contains 648 cells. These 
cells by actual measurement contain iTOj cubic feet of air, and, like the 
cell-house, are very imperfectly ventilated. February 1st, 694 men were 
confined in these cells. During this month the number of prisoners re- 
ceived, was so much in excess of those discharged, that by March 1st, 735 
men occupied these same cells. There are six tiers of cells on each side 
of the house, but those next to the roof, 108 cells, cannot be used, as it 
is almost certain death for any one to sleep in them, especially in sumnier. 



78 Rodman, Miasmatic Infectious Pneumonia. [Jan. 

For tiiis reason partly, and partly because, under any circumstances, the 
number of prisoners is greater than the number of the cells, it is absolutely 
necessary to " double" some of the men. This is done with those who 
occupy the uppermost tiers of cells. The strongest cells are near the floor 
of the building, and are reserved for the whites, who are more apt to 
make their escape than the negroes. The latter exceed the whites, by 
about 50, and are confined in the upper tiers. Now comes a statement 
which is almost incredible. Every man goes to his cell with a night 
bucket, intended to be used only in case of an emergency; but rather than 
wait their turn at the privy, 400 of these men will use their buckets in 
their cells at various times from dark until daylight. The fearful odor 
arising from this source can scarcely be imagined. Whipping with the 
strap, and every legitimate punishment has been tried to prevent this, but all 
to no purpose. Cleanliness in the person of the men is enforced as much 
as possible ; but negroes and whites, when in prison, are very much alike in 
one respect, and it is an exceptional thing to see a prisoner naturally neat 
and clean in his person. The lowermost tier is comparatively free from 
any unpleasant odor, and here there is less sickness than from any other 
part of the cell-house. The odor increases with each tier, and when the 
top is reached, to a person unaccustomed to it, the stench is almost un- 
bearable. I have seen persons gag, as if they would vomit, when going 
into one of the cells on this top tier. The guards tell me they have to 
breathe much more rapidly than usual when making their night rounds 
on the upper corridors. It is now impossible for me to say exactly how 
many from each tier have died with pneumonia, the steward having failed 
to keep the record; but this I know from memory, that at least five-sixths 
of the cases and deaths were from the top tiers of cells. There have died 
in all, from this form of pneumonia, 25 men ; of these, 24 were negroes. 
Counting as new prisoners, all those received from January 1st, 1875, to 
date, they would be in proportion to the old prisoners, about as 1 to 4. 
The records show that 14 out of the 25 deaths were ara@ng the new 
prisoners. This proves a fact, which I have often seen mentioned, that 
a stranger, coming within the sphere of action of any zymotic poison, is 
more apt to contract the disease than one who has, as it were, grown up 
with the development of the poison. During the prevalence of this pneu- 
monia, cases of the ordinary type were received occasionally into the 
hospital. But it was evident, that the two diseases were very ditferent 
in their features. It was remarkable to see a stout rol)ust prisoner, in 
tlie full vigor of life, succumb, and that rapidly, to the infectious form, 
while by his side an old and broken-down man would be convalescing 
from an ordinary attack, and this too where a careful physical examination 
revealed al)out the same amount of lung consolidation in each case. 

I have had but very Mttle sickness in the prison from other sources than 
this pneumonia. There have been in the hospital about 15 cases of ordi- 



1876] Rodman, Miasmatic Infectious Pneumonia. 79 

nary facial erysipelas, and 13 cases of acute rheumatism (to this latter I 
will call attention when I come to speak of the treatment) ; outside of the 
prison walls, I never saw a case of this infectious pneumonia. Frankfort 
and vicinity have been unusually healthy during the prevalence of this 
endemic in the prison — in fact a zymotic disease is rarely heard of. In 
view of all these facts, I am convinced that this pneumonia owes its 
origin to the foul emanations from the cells. Twice before in the history 
of the prison, pneumonia has prevailed to a fearfully fatal e.xtent, and 
this about the time the prisoners became so numerous as to crowd the 
cells. I cannot say positively what form of pneumonia this was, as the 
physicians who had charge of the institution at that time are dead, but I 
have but little doubt that the disease was identical with the one in ques- 
tion. At that time, the causes of pneumonia in the prison were supposed 
to be " taking cold," and the inhalation of hemp dust and lint. 

I do not believe that the latter of these two causes has much to do with 
the prevalence of pneumonia, for the following reasons : There are 450 
men employed in the hemp factory, a large majority of whom are negroes. 
I do nut know that the whites in the factory are more prone to have 
pneumonia than those employed in the chair, blacksmith, and other shops. 
Again, 40 women, all negroes, work in hemp constantly, but, having large, 
well-ventilated cells, they have no pneumonia. On inquiry I liiid, that, 
all through the hemp raising districts of Kentucky, the article is handled 
exactly as it is in the prison, but the negroes so employed are not more 
subject to pneumonia than those following other pursuits. I will not 
deny that hemp may predispose the men to attacks of pneumonia, if they 
have such places as I have described to sleep in ; but that it is the prin- 
cipal factor I cannot believe. Many of the white men, who occupy the 
lower tiers of cells, work in hemp, as do the negroes who occupy the 
upper cells, but even in proportion to the number there are ten times 
more cases of pneumonia among the latter than the former. 

The question has been asked, " whether the hygienic condition of the 
prison was worse when the pythogenic pneumonia prevailed, than it had 
been during the previous prevalence of simple pneumonia ?" The con- 
dition of the men in every respect was the same, as far as I could determine 
by a careful examination of all the surroundings. 

As regards race and color, I do not know but that negroes are more 
disposed to pneumonia than whites ; and when attacked are much less 
able to withstand the eflects of the disease. But if it were practicable, 
and the relative position of the two races in the cell-house were reversed, 
I am certain that more whites than negroes would be the victims of this 
poison. 

One of the prison rules requires the men to be locked up in their cells 
on Sundays, except when at meals or in the chapel. This had to be 
abandoned ; even uow, when on Sundays rains compel the men to collect 



so Rodman, Miasmatic Infections Pneumonia. [Jan 

in the chapel or cell-house all day, an unusual amount of sickness is 
observed the first of the following week. 

I do not regard this disease as a local one by any means. I believe this 
pneumonia, this consolidation of lung tissue, is a local manifestation of a 
constitutional disease. As in typhoid fever, the specific poison, being swal- 
lowed with the food, causes hyperaemia, inflammation, and ulceration of 
Peyer's patches, and infects the system at large, so, in this pneumonia, the 
specific poison inhaled into the lungs produces local trouble as it enters 
the blood and infects the whole body. One strong proof is this : All the 
deaths, but one, which I had from ordinary pneumonia, occurred from 
collateral oedema, or rapid and extensive progress of the inflammatory 
process ; so much so, that in nearly every case I saw, at least one-half of 
the breathing capacity of the lungs was lost. In this miasmatic form I 
have seen men die, and poat-mortem examination reveal probably only 
one lobe hepatized. From this it is evident that something more than 
the amount of lung tissue involved had caused death. 

The symptoms also prove a systemic poisoning. I have seen patients 
when the pneumonia was very slight have violent delirium, so much so 
that one would naturally suppose that the brain was seriously affected. 
This delirium was most apt to occur where the lung affection was not a 
prominent symptom and the eyes showed an icterode hue. The pneu- 
iHonia itself, both as to physical signs ^wA jiost-morlem appearances, closely 
resembled an ordinary pneumonia. In many of the cases, almost pure 
blood was expectorated in large quantities, or the sputa were of a dirty 
brownish-black. Both of these symptoms were indicative of intense inflam- 
mation, and very few patients having them recovered. The tongue was 
frequently covered with heavy yellow coatings, and there would be but 
little desire for food. The bowels did not seem to be much affected, but 
the stools almost invariably had a horribly fetid odour. The urine was 
always a brownish-red, showing that the liver was not performing its 
functions properly. This latter organ was shown by post-mortem exami- 
nation to be enlarged, congested, filled with dark, syrupy blood. In al- 
most every case it pushed up, to a decided extent, the right lung, reaching 
nearly to the fourth rib on that side. Pain was not a constant symptom 
by any means, and ki many cases the lung consolidation was revealed only 
by physical exploration. The heart was almost invariably filled with dark 
blood, and in each ventricle were pieces of fibrin, varying in size from a 
pigeon's to a hen's egg, and sometimes projecting several inches into the 
pulmonary artery or aorta as long cords. The pleura was implicated 
oftener than in simple pneumonia. In two or three cases small circum- 
scribed empyemas were found. The average temperature seldom ranged 
so high as in ordinary pneumonia, and men would die without the rate of 
the pulse or respiration l)eing increased to what would be considered a 
dangerous degree in simple cases. 



1876] Rodman, Miasmatic Infeotious Piieumoiiia. 81 

The disease is very treacherous. To all appearances the patient may 
seem better. No pain, temperature lower, pulse and respiration improved, 
cough and expectoration irrow less, and the patient says he is better. 
But in a few hours the fatal character of the attack would be evident. 

There have occurred in the prison this year (to July 1st) 118 cases of 
pneumonia. Of these, 98 have been of the infectious kind; of these, 25 
have died. I will j?ivc here some cases which will illustrate the disease 
when the patient recovers and when he dies 

Case I. — Guilford B., negro, age 24, very large and well-developed 
man. Was taken sick in his cell on the night of February 23. Had a 
chill; and when he reported himself at the hospital next morning his 
pulse was 112, respiration 32, temperature 104.5°. Was ordered carb. 
ammonia gr. xv, and quin. sulph. gr. iij, every three hours, as he was found 
to have pneumonia of the whole of the right lung. Turpentine stupes 
were ordered to relieve the pain. At G P. M.his temperature was 103.5'-^. 
As his eyes showed that he was jaundiced, he was ordered 10 gr. calomel 
at bedtime. The carb. amnn^n. and quinia were coiitinued. His pulse 
averaged 115, his respiration 35, and his temperature gradually fell until 
it reached 101.5° on March 1, when he died. Post-mortem revealed 
hepatization of entire right lung. 

Case II. — Thomas C., negro, aged 21, very large man, with splendid 
muscular development. Had a chill the night of February 24th ; 25th, 
respiration 44, pulse 120, temperature 103^°. No pain anywhere, but 
physical examination shows pneumonia at apex of right lung. This man 
is decidedly jaundiced, and has delirium. Bowels acting well, but dis- 
charges very fetid. Urine a deep brown. Ordered carb. ammonia gr. xv; 
quin. sulph. gr. iij, every four hours; also liberal diet. Expectoration 
very slight, and indicates nothing particularly. This man's temperature 
from now until he died, March 10, averaged 103°, pulse 110, respiration 
30. He gradually sank, and died with symptoms resembling urgeraic 
poisoning. A short time before death the sputa looked as if they were 
tinged with bile, Ijeiug yellow and frothy. Post-mortem revealed only 
consolidation of the upper lobe of the right lung, with liver enlarged, con- 
gested, and fdled with thick, dark blood. 

In both of these cases stimulants were given freely as soon as the indi- 
cations presented. 

The following are two well-marked, rapid cases : — 

Case III. — Isaac S., aged 31, coloured. Put to bed at 12 M. on April 
22d. Calomel and quin. sulph. aa gr. vj were ordered. At 3 P. M. he 
fell into a profound stupor, could hardly be aroused. Mustard plaster 
was applied over the chest. 10 P. M. whiskey ^ij was given ; at 6 A. M. 
23d, he took 5ij beef tea. He died shortly after. Post-mortem showed 
both lungs (lower lobe of each) in the first stage of pneumonia. 

This case I did not see, as he was taken sick and died between my 
usual morning visits. 

Case IV. — Richard A. (coloured), age 28. May 4th, put to bed to-day 

Pneumonia found in lower lobe of right lung. Tr. mur. ferri gtt. xxx, 

and quin. sulph. gr. iij, every three hours. Temperature 100° ; pulse and 

respiration not recorded. This man died on tlie night of the 6th. On 

No. CXLI.— Jan. 187G. 6 



82 Rodman, Miasmatic Infectious Pneumonia. [Jan. 

the 5th his temperature was 103.5° ; at 6 P. M. on night of 6th, lOl"^. 
Post-mortem showed pneumonia of lower right lobe. Liver congested 
and enlarged ; other organs natural. 

In both these cases the poison seemed to overwhelm the patients before 
there was much time given for the development of any decided local 
changes. 

Case V, — Hank W., coloured, age 24, was taken sick with a chill the 
night of April 30. Came to the hos])ital early on the morning of May 1. 
It was evident from the sounds heard over the root of the right lung- 
that pneumonia was beginning, and would probably invade the whole 
lung on that side. Temperature 104°; pulse and respiration not re- 
corded. Tr. raur. ferri gtt. xxx, and quin. sulph. gr. iij were ordered 
every three hours ; also liberal diet and stimulants. The pneumonia pro- 
gressed rapidly, until, as had been anticipated, the whole right lung was 
hei>atized from apex to base. The expectoration was almost like pure 
blood, but after several days it became a dirty l)rownish-black. Plis tem- 
perature on May 2d and 3d reached 104.5° ; from this time it gradually 
sank to the normal, which was reached on May 21. 

This is a fair example of an ordinary case terminating in recovery, 
except the character and amount of sputa. 

I regret exceedingly that the reports of these cases are not more perfect 
in their details. My apology is, that the steward of the hospital is him- 
self a prisoner, and has so many things to attend to, that he can scarcely 
find time to keep even such records as he has, especially when there is 
much sickness. 

Having had such remarkable success with carb. ammonia in ordinary 
cases of pneumonia, I tried it faithfully in this pernicious form. The 
mortality was frightful. At last I saw my mistake ; I had been treating 
a local symptom for a general disease. I think now that I might as well 
treat a case of typhoid fever by attempting to heal the ulcerated bowel, as 
treat one of these cases of infectious pneumonia by ordinary pneumonia 
treatment. I dropped the ammonia and fought the poison with large 
doses of tr. mnr. ferri and quinia ; at the same time sustaining the patient 
with liberal diet and stimulants in large quantities. The result was in 
every way satisfactory. Cases which I thought would inevitably die (others 
like them had died) recovei'ed, although the recovery was protracted in 
nearly every case. Still there would occur every now and then a " light- 
ning" case, where a man would be so overwhelmed with the poison, as to 
die in a few hours. In these cases I do not believe any treatment will do 
good. 

About the time the pneumonia began to decline, several cases of acute 
rheumatism came into the hospital. I had five cases under treatment at 
one time, all negroes, and the attacks very much alike in severity. I put 
two of these five on quinia 6 grs. every 4 hours, and the other three on 
usual alkaline treatment. Soon the cases treated with quinia improved, 
while those treated with the alkalies either got worse or remained about 



1876.] Rodman, .Miasmatic Infections Pneumonia. 83 

the same. My cour.se was plain. I jiut these three on quinia, and they 
immediately bep;an to improve. Since then I have treated all cases of 
rheumatism coming from these upper cells with quinia, and with satis- 
factory results. And why ? Because, I believe, this same poison is at work 
under a different form, and I know of no better antidote for it than 
quinia. 

A mortality of 25 deaths in 98 cases is still fearful to contemplate, and 
the old adage, "an ounce of prevention is worth a pound of cure," might 
be quoted with great propriety. Whitewashing, burning coal-tar, cleanli- 
ness of prisoners and their bedclothing has accomplished something. 
Bvery window and door is opened that is possible, and all the fresh air 
that can, circulates through the cells. But until this cell-house is razed 
to the ground, and places built fit for human beings to sleep in, such 
scourges must e.xist. 

To sum up under the same head as Drs. Grimshaw and Moore have 
done in their late communication to the Irish Hospital Gazelle (a summary 
of which can be found on page 239 of the July Xo. of the American 
Journal of the Medical Sciences) I will state, 1st. That while pneumonia 
may (and probably the majority of cases do) arise from other causes, still 
there is a form which arises from miasmatic influences. This form is infec- 
tious but not contagious. Here I venture to differ from Drs. G. and M., if 
they use the term contagious as I understand it. I have seen no cases arise 
from contact, mediate or immediate, with a person having the disease. The 
nurses in my hospital who have waited on every one of the cases have never 
had the disease themselves. But if they had slept in the cell-house, instead 
of the hospital building, I have no doubt that some of them would have 
contracted the disease. 2d. I do not know what Drs. G. and M. mean l)y 
the relations existing between this form of pneumonia and other zymotic 
affections, as typhoid fever and cholera. I can see that there is some 
similarity in their being infectious, but in this, it no more resembles cholera 
and typhoid fever than it does typhus, smallpox, or common intermittent 
fever. Never having seen an epizootic pleuro-pneumonia, on this point I 
am silent, od. Its etiology does certainly justify us in classing it as a 
zymotic disease, but I think the name " miasmatic-infectious" better than 
that of " pythogenic" i)iieumonia. 4th. This form of pneumonia presents 
decidedly different clinical features from ordinary pneumonia,. 5th. 
Drs. G. and M. believe that much of the pneumonia which prevailed in 
Dublin, in 1874, was of this type. I can readily understand how this 
can be true in a crowded city, or where the emanations from a drain or 
sewer pollute the surrounding air. I have never seen a case of infectious 
pneumonia outside the prison walls, unless I regard as infectious, those 
cases which arise from subtile ejndemic influence commonly called atmo- 
spheric or telluric. In these last, I venture to say, that the clinical 
features differ very little from pneumonia as generally met with. 6th. 



84 Robinson, Follicular Disease of the Throat. [Jan. 

Pneumonia is generally met with, in this latitude, in cold wet weather, 
with sudden changes of temperature. The infectious form is due almost 
entirely to local causes, and the weather will have very little to do with 
its production, increase, continuance, or decline. I will also state that 
the invasion is decidedly more sudden than in ordinary pneumonia, and is 
less apt to attack the lower portion of the lung (in several of my cases the 
disease attacked the upper lobes only). I do not, with Drs. G. and M., 
think that it is easily arrested in the early stage, or that the disease is 
more amenable to treatment than ordinary pneumonia. Most of my re- 
coveries were decidedly more protracted than recoveries from pneumonia 
generally are. It seems that Drs. G. and M., and myself agree that 
quinia is the best remedy for this infectious form of- pneumonia, though I 
believe the mur. tr. ferri to be a decided adjuvant. The sooner that this 
pneumonia is regarded as a mere symptom of systemic poisoning, and 
treated as such, the better it will be for both patient and physician. 



Art. YII. — On the Pathogenetic Physiology of Follicular Di.nease of the 
Throat and Air-Passages. By Beverley Robinson, M.D.. Surgeon 
to the Manhattan Eye and Ear Hosp. (Department of the Throat), etc , 
New York. 

We desire to invite the attention of our colleagues to some considera- 
tions with respect to an affection which has occupied our thoughts for 
quite a long period. 

The disease to which we have reference is popularly known under the 
name of clergyman's sore-throat. By practitioners of medicine it is more 
scientifically designated follicular disease of the throat and air-passages. 

This latter appellation has several attendant advantages : we are made 
aware of the supposed anatomical seat of the malady ; the morl)id pro- 
cesses so frequently present in the glandular follicles is inferred, and the 
disorder readily assumes its proper nosological place. Already follicular 
disease has been fully and accurately described in very many particulars. 
To the late Horace Green, M.D., of Xew York, we are indebted for an 
admirable description of its rational and physical symptoms. In his 
treatise on bronchitis, chronic laryngitis, etc., he gave us the features in 
detail, which enable us to separate follicular diseise from chronic inflam- 
matory affections of the respiratory tract. 

In the chapter on pathology, however, erasions might now be made 
with advantage to the work, and certain deficiencies supplied. 

Perhaps, therefore, the results of our individual thought and experience 
on this head will not be devoid of interest to our readers. 



1876.] KoinN80N, Follicular Disense of tlu- Throat. 85 

It is not lui/.ariloiis to aflinii tliat of evi'ry half dozen cases of throat 
trouble which may come under our caie, four or five will present in a more 
or less marked degree the so-called "granulations," either on the phar}'nx, 
velum, pillars of the fauces, tonsils — or in fact upon all these parts. Some- 
times these small glistening bodies are no larger than the head of an ordi- 
nary pin, and resemble so ninny minute vesicles of herpes covered over 
with a coating of thick, vi.'jcid mucus, somewhat grayish in coloration, or 
else with a foamy, aerated, spumous secretion, less viscid, and of whitish 
tinge, like that which comes from the bronchial tubes at tlie cominenceT 
ment of an acute inflammation of these latter structures. 

We have seen these glistening bodies, especially when limited to the 
organs above mentioned, and of small size, without concomitant troul)le 
in the naso-pharyngeal space, or in the mucous lining of the inferior por- 
tion of the pharynx, or of the larynx itself. 

Frequently, however, these granulations appear to be but the continu- 
ation of a more or less similar condition which exists in even an exagge- 
rated degree above the soft palate. 

They are then very much more enlarged and of different shapes — rounded, 
oval, oblong in a vertical direction, etc. We have seen these granulations 
accompanying all sorts of diatheses — syphilitic, scrofulous, tubercular, and 
in men and women of almost every profe.ssion. We have had occasion to 
observe them in a very exaggerated form in patients who were little, if at 
all, troubled with abnormal sensations in the tliroat, or with difficulty of 
swallowing, or dysphonic and aphonic phenomena, resulting from deficient 
functional power of the vocal cords. 

Again, we have noticed these same granulations in throats where there 
were very noticeable proofs of a heightened degree of sensibility, and 
where the voice was very hoarse and discordant, reduced to a whisper, or 
entirely lost. Now, how should we interpret these seemingly incongruous 
facts, and what is the real pathological signification belonging to them ? 
Evidently it is not in the granular condition that we should look for the 
explanation of all the morbid phenomena of diverse sorts which show 
themselves in follicular sore-throat. There is something beyond and more 
philosophical to be considered. In our estimation follicular sore-throat 
is not caused nor brought on by any special profession, nor due to any 
particular accidental circumstance, or concatenation of occasional condi- 
tions which may be present more or less permanently. 

No doubt the clerical profession, that of the orator, the auctioneer, the 
public vendor, the car-conductor, in all of which the vocal organ is in very 
constant use, may confirm and prolong this disease when it exists. No 
doubt the inhalation of certain irritant vapours or exhalations, the exercise 
of professions or trades in which one is obliged to be continually in a 
medium where organic particles of a hurtful and pernicious kind are pre- 
sent, may increase a morbid state already mauifest; but much more essen- 



86 Robinson, Follicular Disease of the Throat. [Jan. 

tial to the primary production or development of follicular disease is the 
diathetic or conHtitidional tendeucy which is usually, if not always, present 
in such cases. 

And this diathesis, which, for lack of a better terra, we are compelled 
to call "catarrhal," is to be treated energetically by some substance or 
substances, selected amongst those drugs which are known to be elimi- 
nated from the system through the raucous linings. Mere local treatment 
cannot cure chronic granular pharyngitis. A combination, and a pro- 
per combination, of local and general treatment, is essential in order to 
accomplish this result. Further, there would appear to be, without doubt, 
some relation existing between the granular condition of the throat and 
the herpetic disposition so frequently manifesting itself by eruptions upon 
the integument; and — ^.just as the man who bears this latter in his system, 
and who rightly avoids eating shell-fish, cheese, salt meat, spices, and in 
fact all substances which have an irritating action upon the skin, for fear 
lest an eczema, psoriasis, pityriasis, etc., may be very much aggravated by 
indulgence in dishes formed largely of the above ingredients — so the pro- 
fessions mentioned above ; the use of tobacco, or alcoholic stimulants, even 
in moderate quantities; exposure to a damp, cold atmosphere, to the in- 
halation of irritant and pernicious vapors, will always notably accentuate 
and increase the outward manifestations of the diathesis in which granu- 
lations of the pharynx are so prominent a feature. 

Accompanying well-marked cases of follicular disease, we have frequently 
met with symptoms of difficulty or pain in swallowing. In these instances 
the throat has been intolerant, at times, of all hot or acid food and drink. 

Again, these sensations have appeared to show themselves spontane- 
ously and without intercurrent disease of the crypta, and were not aggra- 
vated in any appreciable degree by the contact of different kinds of nour- 
ishment, or by the effort of deglutition. Occasionally, there was a certain 
periodicity about their return. 

These phenomena, which may change and transform themselves into 
all varieties of curious and unpleasant subjective feelings to which the pa- 
tients apply terras expressive of personal conceptions of their exact nature, 
are not alone encountered in individuals of a peculiarly nervous tempera- 
ment. We have heard strong, robust men complain, as well as those of 
more feeble constitution, and there seems to be a real and intimate relation 
between the condition of the pharyngeal mucous membrane, when chron- 
ically inflamed and thickened, and this local hyperaesthesia of the impli- 
cated parts. No doubt the painful condition of the nervous filaments 
which are distributed to the pharynx is to be found in connection with 
other evidences of great or general nervous derangement. Such cases we 
have met with in women suffering from hysteria, and in these examples, 
inspection of the posterior wall of the pharynx, or of the larynx with the 
aid of the small mirror, did not allow us to discover any organic lesion. 



1870.] Robinson, Follicular Disease of the Throat. 87 

Many of thcin, therefore, may be temporarily placed in the class of "func- 
tional affections." 

This overgrown division must not, however, be needlessly or carelessly 
augmented, and it is for this reason we should impress on our minds the 
importance of duly considering al)normal sensations in the throat, in con- 
nection with a chronically inflamed condition of it, or of neighbouring 
organs. More especially do we think it proper to do so at this present time, 
inasmuch as, owing to several medical articles which have been published 
within the last few months, we find that many practitioners ignore almost 
completely the remote effects which result from morbid states of the pha- 
ryngeal mucous membrane, and are willing that these effects should be 
classed with those other mysterious nerve phenomena which have appa- 
rently no anatomical cause of their production. 

What is the condition of the mucous lining of the pharynx in granular 
pharyngitis ? Is it not frequently thickened, hypertrophied, and does not 
this morbid change involve at times all the soft parts which underlie this 
membrane ? Are not the cellular and muscular layers often affected with 
plastic exudation, owing to the extension of the chronic inflammatory 
processes? And what is the result witli respect to the nerve filaments 
which go to form the pharyngeal plexus ? Primitively respected, as they 
are in many cases, they inevitably end in being affected by the adjacent 
morbid evolution. Nor does this amount of trouble appear to be at all 
in proportion with the amount of the inflammatory condition. In certain 
forms of erythematous sore-throat we have a mucous membrane more 
acutely inflamed than we have in follicular disease, and yet in our experi- 
ence there is less nerve trouble consecutive to it. The hyper-glandular 
development of the air-passages is in some way or another connected with 
chronic neuritis, which, without much cause for doubt, exists in those casCvS 
where there is also much hypera?sthesia. Secondarily, degeneration and 
atrophy of the muscular layer may be recognized, and this is plainly mani- 
fest in old cases of the disease, where we are apt to find the space between 
the soft palate and the prevertebral muscles considerably augmented in 
comparison with what exists in the normal state. The mucous membrane 
shall have then lost in thickness, owing to infiltration of tissue, just as at 
the debut of the disease it had gained in this respect. 

And, in instances of a severe type, the submucous and muscular layers 
are both partially absorbed. Occasionally, too, the mucous membrane is 
so much thinned that we are able to perceive the muscular stritc under- 
neath it. This atrophic state may become more evident on one side of the 
pharynx than on the other, and to such an extent at times, that we might 
almost believe in a deviation of, or tumour arising from, the cervical portion 
of the vertebral column. These results do not appear to us altogether 
analogous to those which we encounter as a result of ordinary chronic 
inflammatory disease. There appears to be a sort of special anatomical 



88 Robinson, Follicular Disease of the Throat. [Jan. 

processus, an infiltration in the beginning, and afterwards an atrophic 
degeneration of tissue which is closely allied with the existence of hyper- 
trophied or otherwise morbidly affected glandular follicles. 

And whenever these glands become ulcerated, as they frequently do, we 
believe that this ulceration may be explained by the want of nerve force 
generated in those peripheral extremities where there exists doubtless a 
condition of interstitial neuritis (that is to say, a multiplication of the 
elements of the neurilemma and the sheaths) and owing to the consequent 
thickening so produced, compression is exercised to such a degree upon 
the nerve fibres that their function is more or less absolutely abolished. 

Not only do we believe it fair to presume that the pharyngeal plexus 
is thus affected, but also the nerve trunks which go to form it, and so we 
are able to account for phenomena of hypera^sthesia and paralysis which 
pass at ouce within the throat and larynx, and manifest themselves con- 
comitantly in the soft palate, the ear, or other remote organ. 

According to Dr. Weir Mitchell, there is a great tendency in neuritis, 
which is especially evident in chronic neuritis, for the morbid condition 
to propagate itself from the periphery towards the nervous centres, and 
thus to involve other branches of the same trunk or plexus originally 
implicated, and this fact will serve to explain some of the phenomena men- 
tioned in the histories that we shall at present endeavour to analyze and 
properly interpret. 

In a small pamphlet, reprinted from the New York Medical Journal 
some months since. Dr. George M. Beard, under the head of "representa- 
tive cases of nervous disease," published that of a young lady from Chicago, 
who, as Dr. Beard describes her, was 

"of a delicate, thoroughly American type, but no more nervous than thou- 
sands of our countrywomen. For one year she had suffered from absolute 
aphonia. 'J'he laryngoscopic examination of her physician and of others, indi- 
cated no local lesion that could well account for her symptoms 

all the accompanying symptoms pointed to a nervous origin of her disease. 
The hyperajsthesia was very remaWvable. 'I'he patient said the pain from whis- 
pering was so great that — to use her own words — ' when I try to whisper I 
suffer terribly, become dizzy, and have pain in my ear.' ' I often feel,' she con- 
tinued. ' as it every word 1 whispered grated on the vocal cords, and to laugh 
would make the cords ache.' Almost continually there was pain in the throat, 
and on this account her nights were wakeful." 

Dr. Beard here remarks: "The evidence was pretty clear that the nerves 
supplying the larynx were in a condition of great hyperajsthesia. producing a 
condition analogous to vaginismus. True it is. the nerves of the larynx were 
evidently affected, in this instance, with a very exaggerated degree of sensibility, 
but so were those of the throat, so also were those of the ear." 

For us this case was an evident instance of the kind we have first studied 
in a general way. The trunk and some of the branches of the pneumo- 
gastrie, near either extremity, were evidently chronically inflamed. As to 
the connection between the ear and the larynx, that is readily explained, 
as we have already had occasion to point ont in a communication by us 
in the Neic York Medical Record of May 1, 1874, and which we shall 



1S76.] BuiiiNsoN. Follifiihir I)ise:ist' of Uif Throat. 89 

lec'iir to at iireseiit. Tlie superior cervical rraiiglioii of tlie va^mis gives 
orifrin to a sensory branch of some magnitude called tlie auricular. 

This branch, first descriljed by Arnold, sends two very small divisions 
to the meatus auditorius, and a third division, alluded to by Sappey, 
which is distributed to the membrana tympani. 

All medical men are familiar with the cough produced by introducing 
an ear speculum, prol)e, or other foreign body into the external auditory 
canal. This physiological phenomenon is satisfactorily accounted for by 
reflex action of the vagus. In the case we quote, the painful sensation 
created upon the vocal cords by the effort of phonation, w^as reflected, or 
propagated along the sensitive nerve tul)es contained in the ])nonmogastric, 
to the organ of hearing. The auricular filaments were, doubtless, in a high 
state of irritability,, or affected after the same manner, as the peripheral 
extremities of the same trunk, within the larynx. 

The following case of (so-called) chronic naso-pharyngeal catarrh illus- 
trates two important facts : 1. The dysphonia which frequently accom- 
panies this condition, when, however, the apparent trouble within the 
larynx is insufficient to account for the imperfect speech. 2. The good 
results which may follow active treatment of the naso-pharyngeal space, 
without any attention in the way of therapeutics being directed to the 
vocal organs. 

R. A., 30 years of age, book agent, came under my care at the Man- 
hattan Eye and Ear Hospital at the beginning of last year. Three years 
ago he could not breathe at all through the left nostril, owing to the 
obstruction caused by the thickened condition of the Schneiderian mem- 
brane. He had lumps on the outside of the neck, and excessive secretions 
from the throat. When he tried to sing he felt pain in the larynx, and 
if he attempted to sound the higher notes his voice immediately became 
discordant and screechy. Somewhat later, his voice was reduced to a 
whisper. Last spring his voice improved, but he still continued to have 
falsetto notes in singing. At the present time (October 1st, 18T4), one 
month after treatment was begun, he sounds high and low notes decidedly 
better than he did, and there is much less secretion from the posterior nares 
and naso-pharyngeal space. The pain of the larynx has also completely 
disappeared. This case was mainly treated by injections of salt-water and 
weak solutions of permanganate of potash, with the use of sulphur-water 
internally. (In parenthesis, I beg leave to state in this place, that, al- 
though I still use watery medicated solutions, passed through the nose by 
means of a Davidson's, Warner's, or ordinary post-nasal syringe, in old 
cases of catarrh of the nose and naso-pharyngeal space, I am more and 
more inclined to believe that these injections are useless, and frequently 
positively injurious, in cases of similar trouble, which date their origin 
but a few months previous to the period wlien treatment is begun.) 

To return to our history : Here then is a case where hyperesthesia of 
the larynx and dysphonia were both benefited by treatment of the nasal 
raucous lining, and of the upper portion of the pharynx, without any 
attention being paid to applications within the larynx itself, and we so 
acted because we could find no evidence in that organ of a diseased condi- 
tion sufficient to account for the impairment of voice. 



90 Robinson, Follicular Disease of the Throat. [Jan. 

The result in this case has proved, we really believe, the correctness of 
the opinion which we had in raind that the trunks of the pneumogastric 
nerves, which He adjacent to the pharj'ngeal walls in their superior por- 
tion, were involved by propagation of the chronic inflammatory processes 
accompanying follicular disease so evidently existent in the neighbouring 
parts. Now we do not mean to affirm that the pneumogastric nerves are 
always affected in these cases with recognizable lesions, for we are quite 
aware that most searching autopsies have been made in a few analogous 
instances, and yet, according to well-known authorities, the trunk and 
peripheral extremities have been found intact. If, however, we take into 
consideration some of the experiments performed upon animals by Dr. Weir 
Mitchell, of Philadelphia, and his legitimate deductions therefrom, and 
though these latter are based upon the effects of traumatic injuries, yet are, 
as Prof. Vulpian remarks, in a late review of his work, " not exclusively 
applicable to themselves, but have a general character which allows us to 
use them in the history of other nervous affections," we shall understand 
why some post-mortems have been negative. 

According to Mitchell, many diseases which we are compelled to call 
functional affections, are allied to congestion of nerve, and traces of this 
pathological condition are not found after death. 

We have already stated that in chronic follicular disease the voice may 
be, and is affected at times, when no visible structural lesion exists within 
the larynx itself. This morbid influence may depend, as we have en- 
deavoured to establish it, upon a chronic inflammation of the nerve trunk. 
But there are cases where, though the morbid action of the pneumogastric 
is evident, this action is intermittent, lasting a while and then disappear- 
ing, recurring at intervals more or less periodical, brought on by the action 
of some local irritant applied directly to the pharyngeal walls, or again 
modified favourably and almost instantaneously by a few swallows of some 
indifferent or bland fluid; such examples, we believe, should come under 
the head of congestion of nerve, or a morbid alteration, with reference to 
which we have had, prior to Dr. Mitchell's experiments, only the most in- 
complete notions. 

Let us cpiote from Dr. Cohen's work on Diseases of the Throat (p. 164). 
Speaking of what is frequently observed to occur in public s{)eakers, he 
continues: — 

" They gradually become hoarse during prolonged or energetic harangue, and 
relieve the hoarseness at once by swallowing a little water. Now the water 
goes down the gullet and not into the larynx. True, a little water, but a very 
little indeed, does sometimes trickle into the larynx down the inter-arytenoid 
fold, but it is hardly enough to moisten the vocal cords and larynireal mucous 
membrane sufficiently to account for the improvement of voice which follows 
the act. AVe have to fall back upon the theory tiiat the impression made 
upon the divisions of the pneumogastric nerve distributed to the pharynx, 
oesophagus, and stomach, is propagated to those other branches distributed to 
the larynx. In the same manner," says Dr. Cohen, " a pharyngeal irritation 
will produce hoarseness iu a larynx healthy in every respect. This I have seen 



1876.] Hutchison, Contributions to Operative Surgery. 91 

again ami again ; and have often seen it follow the a]>plication of nitrate of 
silver to tlie surface of but one or two groups of enlarged pharyngeal follicles; 
as well, also, as result from a more extensive cauterization of pharynx."' 

Tlie above facts, taken in connection with wliat we have said {)reviously, 
appear to us to be satisfactorily interpreted if we may suppose that 
aii£Emia of nerve tissue on the one hand, congestion on the other, can 
produce in man accurately dcGned symptoms. 

New York, June, 1S75. 

[Since writing this article we have given proofs of the identity of this 
disease with follicular disease of the throat and air-passages in a paper 
read before the New York County Medical Society, Septemljer 27, 1815.] 



Art. VIII. — Some Contributions to Operative Surgerij. By Jos. C. 
Hutchison, M.D., Surgeon to the Brooklyn (New York) City Hos- 
pital, Consulting Surgeon to the King's County Hospital. 

Case I. Ligation of the External Iliac Artery {left side) for 
Aneurism of the Femoral Artery; Recovery. — S. J. C, set. 43, pre- 
sented himself about March 1, 1874, complaining of a small lump in his 
left groin. He had always enjoyed good health ; had been a hard- 
working man ; had been engaged among car horses, and was often called 
upon to make sudden and violent exertion. He was not conscious of 
having sustained any injury at the seat of the tumour, although he had 
been in the habit of carrying a carpenter's rule in the left pocket of his 
pantaloons, and may, possibly, liave injured himself by it. He never had 
had constitutional syphilis. About February 15, after severe muscular 
exercise, the patient began to experience pain along the left thigh and 
leg. On February 27 he noticed, for the first time, a lump, about one 
inch in diameter, in his left groin. Plis family physician saw him, and 
diagnosticated aneurism. I saw him March 1, and found the lump above 
mentioned lying just underneath Poupart's ligament, presenting all the 
symptoms of aneurism. The bruit, though present, was the least promi- 
nent of the signs. Drs. Willard Parker and James M. Minor, of New 
York, saw the case in consultation, and confirmed the diagnosis. After a 
week's rest and low diet, which reduced the patient's strength materially, 
without any appreciable effect on the aneurism, it was dec'ded to ligate 
the external iliac artery. 

On the 1 1th of March, at noon, after having the bowels freely moved 
by oleum ricini, the patient was placed upon the table and anaesthetized 
with ether by means of Dr. Squibb's apparatus. An incision was then 
made from about the middle of Poupart's ligament, upwards and out- 
wards, to a point one inch within the anterior-superior spinous process of 
the ilium, and on a line with it. The tissues covering tiie artery having 
been carefully cut through down to the fascia transversalis, this fascia 
was cautiously opened and incised upon a director. It was then found 
that, although the incision had been made with the greatest care and 
deliberation, the peritoneal cavity had been opened. To com[)licate the 



92 Hutchison, Contributions to 0[)erative Surgery. [Jan. 

result, the patient commenced to vomit, and the intestines, which were vio- 
lently protruded through the opening, were forced back and retained, by 
pressure, until the vomiting ceased. The artery was now found pulsating 
at tlie bottom of the wound, and, by means of a carbolized animal ligature, 
was tied at its middle third, the ligature cut off short, and returned into 
the abdominal cavity. Pulsation immediately ceased in the aneurismal 
sac and artery; the edges of the wound were united by eight deep silk 
sutures, a compress applied, and bandage outside this. The liml) of that 
side was inclosed in cotton, the patient put into bed, and bags of warm 
salt, and afterwards, on account of being lighter, bags of warm oats were 
placed on either side and over the limb, with a pillow underneath. He 
was ordered pil. opii every two hours. In the evening he was feeling 
comfortable; pulse 88. From the day of the operation he continued 
gradually to improve, and on the evening of the 16th inst. a weak pulsa- 
tion was felt, for the first time since the operation, in the posterior tibial 
artery; pulse 72, temperature 99° ; no pain or tenderness. 

On the morning of the ITth the bandage was removed from the abdo- 
men, two stitches extracted, and one drachm of bloody pus evacuated. 
The wound was then treated with the carbolic acid dressing ; pulse 88, 
temperature 102°. In the evening the patient felt better; pulse 76, 
temperature 99^°. 

On the 18th two more stitches were removed; and, on the 19th, the 
remaining stitches. On this day (19th) the patient had three natural 
fecal evacuations, without pain or uneasiness ; pulse 60, temperature 98^°. 
Pilulae opii twice daily. 

On the 20th the dressing was removed from the leg and thigh ; no 
pulsation in the aneurism ; sac somewhat smaller than before the opera- 
tion. On the 23d the opium was omitted ; on the 25th a slight dis- 
charge still continued from the wound. A few days subsequently the 
wound healed, and the patient was soon able to go about the house. The 
discharge, which was very slight, was watched carefully during the whole 
time it continued, but the ligature was not seen. The presumption is 
that it was dissolved and absorbed, or became encysted. 

The points of interest in this case were, the absence of symptoms of 
peritonitis, notwithstanding the injury done to the peritoneum, and the 
exposure of the intestines; the use of the carbolized animal ligature; the 
almost entire absence of constitutional disturbance, except on one day 
only (and this exacerbation was accounted for by the evacuation of a 
teaspoonful of bloody pus); the location of the sac; and the permanent 
cure, there being no return of the pulsation in the aneurism during the 
subsequent year and six months. 

Case II. A Modification of Sir A. Cooper'' s Operation for Varico- 
cele. — E. W., ast. 20, consulted me, at the request of Dr. Nathaniel Mat- 
son, in the latter i)art of January, 1874, for the purpose of having an 
operation performed for the cure of a varicocele, which palliative treat- 
ment, for several years, had not relieved. 

The following operation was performed, on February 5th, without an 
anaesthetic. The scrotum was spread out, and put well upon the stretch 
by Dr. Kushmore; an acupressure needle was then passed through the 
scrotum, from before backwards and from behind forwards four times, be- 
ginning one quarter of an inch from the left border, and one and one-half 



I8T6.] Hutchison, Coiitril)iitioiis to Opera'-ive Surgery. &3 

inclies al)ove the lower margin, and terminating on the right side, tra- 
versing the tissues from left to right, somewliat after the manner of the 
acupressure needle in Pirrie's 4tli method of acupressure. 

The tissue behnv was then removed with scissors, and the ])arts drawn 
together, like tlie mouth of a purse, by a silk thread thrown over tiie head 
and point of the needle in the form of a figure of eight, and drawn suffi- 
ciently tight to arrest hemorrhage. Only a few drops of blood were lost. 
There was consideraI)Ie swelling and eccliymosis following the operation, 
and some pain, which was relieved l)y a hypodermic injection of morphia. 
On the 1 0th the needle was withdrawn, and the edges had united for one- 
third the length of the wound by primary union. The other two-thirds 
united by granulation. 

On the 28th the patient had entirely recovered from the effects of the 
operation, and from his varicocele. 

The writer proposes, in the next case of varicocele that presents itself, 
requiring operation, to transfix the scrotum five or six times with the 
needle, with the expectation that acupressure alone will arrest or prevent 
hemorrhage without the use of the thread to pucker the tissues ; or, if it 
should be found necessary, on account of hemorrhage, a small rubber band 
maybe thrown over the head and point of the needle to increase the 
pressure on the vessels. Should swelling of the tissues take place, the 
rubber will yield so that constriction will not occur. 

The advantages of this modification, over the usual operation, are: — 

1st. We avoid a large open wound with extensive exposure of the cut 
tissues to the air. 

2d. No ligatures are required, and secondary hemorrhage is less likely 
to occur. 

The tissues involved in the operation are very vascular, and a great 
many vessels must be separately closed. The retraction of the dartos, 
which takes place as soon as the parts are incised, arrests the bleeding 
from many of the vessels, and when relaxation and reaction occur, hemor- 
rhage is liable to take place. It is by no means unusual, after Sir A. 
Cooper's operation, for the surgeon, a few hours subsequently, to find the 
scrotum distended with blood, necessitating the removal of the nicely ad- 
justed sutures, and the securing of the bleeding vessels. 

Case III. Enlargement of the Bight Testicle ; Employment of Es- 
march'' s Method in, its Removal. — I was requested, by Dr. Tennis 
Schenck, to see, with him, Mr. A., set. 38, who noticed, two years ago, 
for the first time, a small lump in the middle of the outer aspect of the 
right testicle. He could give no cause for its appearance : There was no 
history of hereditary malignant disease in the family, nor was he aware of 
ever having received a blow or any other local injury. This small lump, 
not more than half an inch in diameter, was painless, and gave the patient 
no inconvenience whatever. It continued gradually to grow, until the 
present time, and it now involves the entire testicle. His present condi- 
tion is good, and he is able to do his work — farming. The scrotum is 
distended by a smooth, firm, elastic tumour, about six inches in its long 
diameter; the skin overlying it is as healthy in ap|)earance as on the 



94 Smith, Treatment of Ununited Fracture. [[Jan. 

other side, except at one point, wliere an exploring needle had been intro- 
duced : this was the seat of a small abscess. The inguinal glands were 
not involved, and the tumour gave him so little trouble that he did not 
consider it a bar to marriage. 

The operation was performed as follows : After the patient had been 
etherized, a piece of rubber tubing, half an inch in diameter, was drawn, 
twice, tightly around the upper part of the scrotum and tied ; an acu- 
pressure needle having previously been passed underneath the spermatic 
cord, and a wire thrown loosely, in a figure of eight manner, around it, to 
be subsequently tightened in case the rubber tubing should not control the 
hemorrhage from the cord ; a single incision about five in-ehes in length 
was then made, and the tumour turned out and cut off at the upper end 
with scissors. A single ligature was applied to the spermatic cord, and 
the tubing and acupressure needle were removed. The patient lost less 
than a tablespoonful of blood. The edges of the wound were brought to- 
gether by sutures, and the patient was doing well until the second day 
after the operation, when he was attacked with scarlatina, and died on 
the fourth day, the wound continuing to present a normal appearance up 
to the time of his death. The tumour \veighed 30 oz. ; was covered at 
all points by the tunica albuginea ; contained no cysts ; was made up of 
a fleshy-looking tissue, with white trabeculge running through it ; at the 
lower end could be seen the remains of the epididymis. It was examined 
])y the Microscopic Committee of the Kings Co. Medical Society, and no 
abnormal tissue was found in it. The tumour was pronounced a simple 
enlargement of the testicle. 

A chief point of interest in the above case was the satisfactory use of 
Esmarch's bandage, in an operation of this kind, permitting a large inci- 
sion through very vascular tissues with the loss of an insignificant amount 
of blood. 



Art. IX. — On the Treatment of Ununited Fi^acture by "Pressure and 
llotion,^^ ivilh Cases. By Henry H. Smith, M.D., Emeritus Professor 
of Surgery in the University of Pennsylvania. . (Witi) four wood-cuts.) 

Case I. Oblique Fracture of the Bight Femur with Oblique Frac- 
ture of both Bones of the Bight Leg ; non-union after six months^ treat- 
ment; cured in five months whilst ivalking about.— rl am indebted to Dr. 
Wm. R. Blakeslee, of Coatesville, Pa., for the following notes of this 



On the 1st of July, 1873, H. W., aged 33 years, being on a freight train 
going at ordinary speed, attempted to get otf from the front i)latform of 
a "house-car" (last of train), when a rod of iron, to which he held, be- 
came detached, causing him to fall backwards and strike against a coal 
car, thus whirling him partitilly around off the platform on to the ground 
between the tracks, he lighting on his feet, and falling immediately forward 
in the same direction as the train was running, producing bodily concus- 
sion, lacerations, and contusions, with an oblique fracture of the middle 



1876.] Smith, Treatment of tjinmited Fracture. 95 

third of the rirjht femur as well as an ol)]i(|ue frfictiire of both bones of 
the ritjht leg-. 

The limb was dressed by extension and straight splints with such modi- 
fications as seemed expedient diiring the first six months of the patient's 
illness, without any union occurrinp: either in the hones of the leg or in the 
femur. No elfort was si)ared to promote the welfare and comfort of the 
patient during this treatment as regards room, bed, ventilation, and nu- 
trition. His appetite was good, and ]iain not excessive, requiring ano- 
dynes otdy during the first few days after the accident. On November 21st, 
it was decided to treat the case by " Smith's artificial limbs for ununited 
fracture," Fig. 1, but owing to various circumstances their application, with 
an attempt by the patient to walk, was not made until Jan. 1, 1874, six 
months after the injury. It was so long since his muscles had been exer- 
cised that in his first attempts he seemed like a child beginning to walk 
alone, was compelled to use crutches, and also have assistance from a friend 
to give him confidence. This being also the most inclement part of the 
year, his exercise was limited to the house until April, when he was out of 
doors most of his time. He continued the use of the apparatus until the 
middle of May (four and a half months), when he took it ofi' occasion- 
ally. Soon afterwards he laid it aside entirely, and is now (May 5, 1875) 
walking well, and with but trifling lameness, this being apparent especially 
on ascending stairs. 

Case II. Comminuted Ununited Fracture of the Right Femur of 
nineteen montlis' standing; extreme mohilitxj of the fi'agments ; ina- 
bility to stand or use the limh ; immediate ability to walk ivith only a 
cane, as soon as the apparatus was ajyplied. — Col. Jno. W. T., of Iowa, 
aged 56 years, was thrown from his wagon on May 20th, 1873, break- 
ing his right femur at the union of the middle and superior third, and 
also just below the trochanter major, thus making a comminuted frac- 
ture, of which the middle fragment was nearly the entire u])per third of 
the shaft of the bone. The soft tissues were not much bruised ; there 
was no discoloration of the skin, nor was there any appearance of in- 
flammation in the soft parts during the treatment of the fracture. The 
limb was immediately dressed with a long, straight splint, and extension 
made, the patient being kept at perfect rest for nine weeks, when the splint 
was removed, and he was allowed to sit up in bed. At this time there 
appeared to be partial union at the upper end of the intermediate fragment 
near the trochanter, but there was no union at the lower end of it where 
it joined the inferior third of the shaft, near the middle of the thigh. At 
a consultation of surgeons about the eleventh week after the accident, it 
was decided to introduce a seton between the fragments in the middle of 
the thigh. This was done, but on the eighth day subsequently, owing to 
the violent inflammation of the thigh, high fever, and general constitu- 
tional disturbance, the seton was removed. Ten days after this, when 
these symptoms had subsided, the limb was again dressed with the straight 
splint, and the patient confined to bed on his back for seven weeks more. 
At this time, twenty weeks after the injury, there being no indication of 
the slightest union, and his general health being much impaired by con- 
finement and suffering, he was permitted to move about on crutches, the 
limb being bandaged, and partially supported by splints. This gentleman 
had always enjoyed unusually good health ; never had any disease likely 
to retard the union ; had led a very active life, especially during the war, 
when he was on a prominent general's staff, and was unable to explain 
his condition. 



D6 Smith, Treatment of Ununited Fracture. [Jan. 

Dec. 9lli, 1874, he consulted rae in Philadelphia. At the examination 
made at this date it was evident that there was no union in the middle of 
the thigh, as the leg and knee, and lower third of the thigh could bebenf 
laterally at a right angle icifh the axis of the limb, whilst the muscles, etc., 
could be so twisted on the axis of the femur, that the calf and heel could 
be turned iipicards ichilst the patient lay on his back. The upper frac- 
ture was also ununited, but adhesions, etc., rendered it firmer. The point 
where the seton had passed was also quite plain. Of course the limb was 
useless as a support, and dangled loosely on attempts to walk. After 
being well fitted with the apparatus by E. Spellerberg, of No. 105 South 
Tenth Street, he could at once walk with only a small cane — used more 
for confidence than support — the fracture and weight of the body being 
firmly supported by the artificial limb. This patient was carefully ex- 
amined by members of the Philadelphia County Medical Society when 
shown to that body. The uselessness of the limb as a support was very 
apparent to all, as well as the ability of the patient to walk the entire 
loigth of the Society's hall, as soon as the apparatus (Fig. 1) was 
adjusted, thus immediately illustrating one of the points claimed for this 
mode of treatment, viz., that amputation for an ununited fracture was 
unnecessary, the patient's liml) with the apparatus on, being more useful 
for support and progression than the stump could be after an amputation. 

With such an injury tliere was little hope entertained of union, yet the 
usefulness of the limb with the apparatus was entirely satisfactory to the 
patient, his progression being impossible without it. 

Whilst penning these notes I received a letter from Col. T , dated Iowa, 
Oct. 15th, 1875, in which he says : " My poor, broken thigh remains as 
when I left you (Dec. 18th, 1874), eleven months since. Your apparatus 
enables me to walk about readily for short distances, but when I wish to 
go a mile, I take my crutches or mount an old riding horse that is per- 
fectly gentle. There has been a little shortening, which will require a 
slight addition to the heel of my shoe. My general health and strength 
have considerably improved since I saw you." 

Case III. Simple Oblique Fracture of both Bones of the Left Leg ; non- 
union at the ninth iceek ; cured in twelve weeks ichilst icalking about 
and attending an office. — Mr. D. L., aged 74, whilst bathing in the surf 
on the shore of Rhode Island, was upset by a heavy wave, and fractured 
both bones of the leg, the fibula being broken near its lower fifth, and the 
tibia obliquely near its middle. There was nothing unusual in the injury, 
except the slight pain after the accident. Being at a seaside hotel, he was 
temporarily dressed with a " fracture-box" for about fourteen days, and 
then a plaster of Paris bandage applied, after which the patient was per- 
mitted on the third week to sit up and move a little on crutches. During 
the eighth week union was nearly firm in the fibula, but a false joint was 
apparent in tiie tibia, permitting considerable lateral motion. The leg 
was also shortened about three-fourths of an inch, and there was marked 
angular deformity anteriorly and internally, the sharp point of the spine 
of the upper end of the lower fragment projecting so as to inflame the 
skin, and threaten ulceration. On the ninth week after the injury, he 
was moved by his physician to Philadelphia, with the plaster bandage on, 
and placed in my charge. On removing the dressing, the want of union 
in the tibia and the angular deformity caused by the sinking of the heel 
in the bandage were very apparent. The general health was good. After 
making as much extension of the fragments as was possible, the measure- 



1876.] Smith, Treatment of Unmiiled Fracture. 97 

ments for an n]ipnratus were accurately taken, and the "artificial limb" 
(Fipr. 2) made and applied. Consideral)le difliculty was at first ex]icrienced 
in making pressure l)y the apparatus at the seat of fracture in the tibia, 
owing to tiie projection of the sharp point of the displaced lower frag- 
ment which threatened to inflame the skin, but by hollowing the front 
splint at this point, this was accomplished. Soap plaster spread on kid 
was also applied, to protect the skin from too much pressure, and the 
patient was at once able to walk with crutches. Being directed to wear 
the apparatus night and day, and walk constantly about his chamber, he 
was enabled in about two weeks to come down stairs and move about 
more freely. After eight weeks of this exercise, being out of bed all day, 
union had evidently become firmer, and on December IGth, twelve weeks 
after the ap]iIication of the apparatus, union was perfect. 

On February 2d, 1875, he was able to walk without a cane, and since 
then has the free use of the liml), a high heel to his shoe overcoming the 
shortening. 

The advanced age of this patient, his nervous temjierament, his frelful- 
ness at confinement to bed, and his despondency at the failure of the first 
treatment of his fracture, all illustrated the great comfort and success 
derivable from a mode of treatment which gave him the benefit of fresh 
air and exercise. 

Case IY. Ununited Fracture of both Bones of the Bight Leg; failure of 
the operation of perforation, etc., of the bone ; patient able to walk freely 
on the "Artificial limb.'''' — Mr. J. W., aged 40 years, was thrown from 
his buggy in Batavia, New York, on August 2d, 1873, and received a 
compound fracture of I)oth bones of the leg. He was treated at his home 
for nine weeks with a "starch bandage," and the fragments being sup- 
posed to have united, he came to Philadelphia on business. Eight months 
subsequently, as union was imperfect, he consulted a surgeon, who operated 
by "drilling the bones" and refracturing the fibula, in February, 1874. 
Under this treatment, he was confined to bed six weeks, and then dressed 
with a silicate of soda bandage and tin splints. Although able to move 
in this with the assistance of crutches, and his general health improved, 
union was not obtained, and j)rogression being unsatisfactory to the 
patient, he obtained, on his own judgment, from a cutler an imperfect form 
of "Smith's apparatus," which he commenced to wear January 1, 1875. 
When I first saw him his weight was 275 pounds. There was no union 
in the tibia, and he could not walk without assistance. Directing him to 
obtain a well-fitted artificial limb, he was soon able to walk with only a 
cane and attend to active business. To-day (Nov. 1st, 1875), the patient 
reports the bone as firmer but not healed, and that he can walk to his 
satisfaction without a cane, though using one for confidence. The amount 
sustained by the apparatus on this ununited tibia may be understood by 
reference to the patient's weight as before stated (275 pounds). 

Case V. Fracture of the Tibia through the Internal Malleolus and of 
the Fibula in its lower Fifth; laceration of the internal lateral ligament 
of the ankle, and iMrtial luxation outwards of the foot ; patient able to 
sit lip and travel on the fourth iveek after the accident with the apparatus. 
— Mrs. K., aged 30 years, in good health, and weighing 180 pounds, fell, 
July 30th, 1875, on a waxed floor, and fractured both bones of the right 
leg at the ankle, breaking the tibia obliquely through the internal malleo- 
No. CXLI.— Jan. 1876. 7 



98 Smith, Treatment of Ununited Fracture. [Jan. 

Ins up into the shaft, and the fibula obliquely two inches above the joint, 
lacerating the internal lateral ligament of the ankle, and partially luxat- 
ing the foot outwards. Siie was immediately carried to bed; extension 
made so as to reduce the luxation and fracture, and the limb dressed with 
a fracture box and cold water clothes. The sharp point of the lower end 
of the upper fragment nearly penetrated the skin, and swelling and marked 
bloody effusion around the ankle promj)tly followed. The inflammation 
being subdued, she was dressed on the 18th day with side splints, and the 
suspensory frame of Salter of England. On August 24ih the limb was 
placed in the apparatus for ununited fracture, and to give a correct idea 
of the patient's frame, it may be stated that the circumference of her calf 
was 172 inches, and of the middle of the thigh 22^ inches. 

This lady was enabled to sit up out of bed as soon as the apparatus 
was applied, and on August 29th, travelled by carriage and steamboat to 
Newport, Rhode Island, and the next day, four weeks after the injury, 
rode about the hotel entries in a wheel chair. On Se[)tember 30th, eiglit 
weeks after the injury, she travelled nine hours, with two changes of cars, 
to her home in Vermont, where she arrived safely, and was able to walk 
with the apparatus. 

A letter from Mrs. K., Jated Oct. 27th, says: "After my safe arrival on the 
tenth week after my injuries, I started with two canes and began walking on 
my injured limb. The fracture seems all right, and I do not feel any pain 
except in the ankle, which yet feels sprained. I am able to walk about the 
house and up and down stairs without any assistance, and I only use the canes 
out of doors. I commenced to leave the apparatus off at night on the tenth 
week. I have only ventured ou walking a few steps barefoot without the appa- 
ratus to see whether both limbs were of the same length, but the limb is yet 
so weak that I dare not attempt walking without the splint." 

In the varied plans recommended for the treatment of ununited fracture, 
the greatest confidence is apparently felt by surgeons in an operative treat- 
ment, such as the seton, resection, drilling, pegs, etc., yet this is hardly jus- 
tified by the result, the failures after such operations being numerous, and 
the suffering, confinement to bed, and risk to life, such as frequently to excite 
serious apprehension, whilst amputation has been resorted to, in order to 
get rid of an apparently useless limb. Impressed with similar results in a 
case in which I performed resection with caustic, etc. (the patient barely 
escaping with her life), and recalling the influence of pressure on the peri- 
osteum in developing new bone, as shown in the formation of a new aceta- 
bulum by pressure of the head of a luxated femur on the dorsum of the 
ilium, or the head of the humerus on the neck of the scapula, I suggested^ 
in the American Journal of the Medical Sciences, N. S. vol. xv. p. 84, 
1848, the advantage of treatment by an apparatus which, whilst sustain- 
ing the weight of the body and enabling the patient to walk and obtain 
the benefit of exercise iu the open air, yet made such friction on the peri- 
osteum of the adjacent fragments as would lead to the formation of an 
ensheathing callus. 

After an experience of twenty-seven years, this method of treating un- 
united fracture yet retains ray confidence, and I have felt justified, on the 
occurrence of these recent cases, in again recommending it to the considera- 



187G.] Smith, Treivtment of Uiiuniled Fracture. 9? 

lion of tlie profession. The lady previously referred to (Amer. Journ. Med. 
Sci., vol. XV. X. S.) on whom the apparatus was first applied, still enjoys 
excellent hciilth — twenty-eight years after her accident — has had a second 
family of children, and walks well, although union Tiever became firm 
enough to enable her to move without the "artificial liml)." In the 
American Journal of the Medical Sciences, January, vol. xxi. p. lOG, 
1851, also vol. xiv. N. S. p. 117, I illustrated the results of this treatment 
as far as I could obtain returns from surgeons who had employed it, as well 
as from my own practice, I also reported in my work on the Principles 
and Practice of Sur(jery, Phila. 1863, a case of false-joint in both bones 
of the leg of 18 months' standing, cured in five months whilst the patient 
was walking about; another of both bones of the leg of 4 months' stand- 
ing, cured in 19 weeks — both by Dr. Waters of Maryland ; one of the 
femur of 5 months' standing, cured in IV weeks; another of the femur 
of 6 months, cured in 9 weeks under my own care; " false joint" of the 
femur of 20 weeks' standing, cured in 6 weeks by Dr. Levis of Philadel- 
phia ; and "false-joint" in the humerus of 6 months' standing, cured by 
Dr. Dock of Harrisburg, in 3 months, whilst the limb was freely used in 
"setting type." Another of the humerus by Dr. Ashby of Alexandria, 
which enabled the patient to use the limb at the time, with several others 
as there mentioned. Cures have also been frequently shown to the students 
in attendance on the surgical clinics of the University of Pennsylvania. 

Since 1862 I have frequently heard from cutlers of orders given for the 
apparatus, but have been unable to obtain a satisfactory report of the 
treatment from the surgeon ordering it. Sufficient evidence has, however, 
been presented to show that the results of the treatment by " Pressure 
and Motion" should not be forgotten, nor its advantages overlooked by 
the profession. 

Experience having led to some slight modifications of the original appa- 
ratus, and many of the cutlers having failed to manufacture it as described 
by me, often spoiling it in attempts to modify it to their taste, I here offer 
drawings clearly showing the forms now applied to the femur, tibia, and 
humerus, in all of which it has been successfully employed. 

Fig. 1. Artificial Limb for Ummitcd Fracture of the Femur. — A. Pelvic 
hand. B. Hip-joint. C. Conical thigh piece which supports the weight of 
The body and makes pressure ou the fractured ends of the bone, permitting 
sufficient friction to excite periosteal action. D. Knee-joint in side irons. E. 
Support at calf. F. Laced shoe and ankle-joint. 

Fig. 2. Artificial Limb for Ununited Fracture of the Tibia.— A. Support 
at middle of thigh. B. Knee-joint in side irons. G. Main support of the 
body by accurate adjustment below the tubercle of the tibia. D. Ankle-joint 
and boot. 

Fig. 3. Artificicd Limb for Ununited Fracture of the Humerus fitting close 
over the rotundity of the shoulder and forearm, and accurately jointed at the 
elbow. 

Fig. 4. Artificial IJmb for Ununited Fracture of the Forearm — A. Piece 
accurately embracing the arm. B. Joint for flexion and e.xtension of forearm 
at elbow. B. Pivot-joint permitting rotation of head of radius in semi-prona- 



100 



Smith, Treatment of Ununited Fracture. 



[Jan. 



tion and supination. C. Ensheathinfi: piece for forearm. D. A thick pad to 
press on styloid processes of ulna and radius at their carpal surfaces — so as to 
preserve the parallelism of these bones. 



Fig. 1. 




1870.] Smith, Treatmeiit of Uiiuinted Fracture. 101 

In the manufacture of nil tlioso limbs tlio cutlor should use for tlic side hars, 
tliiit are the main support, " cased steel," rt inch wide and J of ineh thick, 
which is stronjj enoiiu^li to sustain any ordinary weii^ht. For the back and 
front splints that surround the limb, and act as a ferule at the seat of fracture, 
take "falvanized sheet-iron. No. (J, stutl'ed with wool, covered by buckskin ou 
the inside of the splint and morocco on the outside. The attempts of some 
cutlers to make lighter limbs, l)y using stiff leather and steel lialf rings, has 
not proved advantageous — the failure of the artificial limb thus made being 
uroved in Case IV. of this paper. The following measurements, if accurately 
taken, will suffice for any good instrument maker: First, state the limb re- 
(piired, viz.. femur or tibia, and whether for the r/(j]i( or hft side. Second, for 
the femur (Fig. 1), give the Uniijlh in inches from sole of foot to perineum — 
from foot to ankle-joint — ankle to centre of knee-joint — knee-joint to trochanter 
major — bip-joint to crest of ilium. State also the circumference above crests 
of ilia; of thigh close to groin; of middle of thigh above knee; around middle 
of knee-joint; around tubercle of tibia ; midille of calf; below the calf; around 
ankle-joint; around point of heel and ankle; around instep; around ball of 
toes. 

The length of the foot should be given for a loose shoe, which should be slit 
entirely down the front, and made to lace. The heel depends on the shorten- 
ing from the fracture. Similar measurements are required for the tibia, except 
that the apparatus (Fig. 2) need not extend beyond the middle of the thigh. 

For the humerus (Fig. ?>) give the lenylh from acromion to point of external 
condyle; from condyle to styloid of radius ; from internal condyle to styloid 
of ulna; and the ciraunferenceN from ])oint of sliouldcr to opposite axilla; 
around top of shoulder over deltoid ; around middle of arm; at elbow-joint; 
ujtper end of forearm, also its middle, and at wrist. For the forearm take the 
same measurements as high as middle of humerus, being careful to take cir- 
cumference at wrist, whilst the radius and ulna are parallel or between prona- 
tion and supination (Fig. 4). 

When obtainable, these limbs may be safely applied to recent fractures, 
so as greatly to diminish the confinement to bed, as shown in Case V. 

With these measurements any cutler can readily make and forward a 
suitable apparatus, which, if failing, as it seldom does, in obtaining a per- 
fect union, will yet enable the patient to use his limb with great comfort 
and facility — hence the name of "Artificial Limb for False Joint" applied, 
by the instrument makers. 

In every application of the ai)paratus let it be remembered, 1st, that the 
pressure at the seat of fracture must be as great as can be borne witliout 
inflaming the skin — hence the strap at this point must always be firmly 
drawn so as to make the apparatus also act as a ferule around the ends of 
the fragments. 

2d. That in the lower e.xtremities, the weight of the body is sustained 
by the upper part of the Jiollow splint, just as a stump is sustained in an 
artificial limb after amputation. The upper strap should, therefore, be 
firmly drawn when the patient is about to walk; but it should be slack- 
ened, so as to be more comfortable, when the patient is in bed or sitting 
np in a chair. 

3d. When worn for several months the inside lining and stuffing should: 
be renewed, so as to give accurate support. 

4th. When from union occurring it is i)roposed to lay aside the splint,. 



102 IIoLPEX, Mortality of Mariners, Railroad Men, etc. [Jan. 

let it be taken off at night for ten days, or whilst sitting np in a chair, 
Ijefore any attempt is made to walk without it. 

5th. It is useful in recent fractures, enabling the patient sooner to 
sit up. 



Art. X. — Belative 2IortalUy of Mariners, Railroad Men, and Travel- 
lers. By Edgar Holden, M.D., Ph.D., of Newark, X. J. 

To whatever peculiarity of our human nature it may be ascribed, it is 
yet a singular fact that we ignore the beam in our own eye, while we see 
clearly the mote that is in the eye of our brother. And this peculiarity 
is nowhere more manifest than when the healthfulness of a property of 
which we may be the owner, or the occupation to which we owe our live- 
lihood, happens to be in question. The steel grinder, whose parents and 
brothers and associates at the stone have died of consumption, will stren- 
uously maintain hi? view of the superior healthfulness of his trade ; and 
the etcher and wool carder, the zinc and copper smelter, and even the sub- 
marine diver will, almost without exception, do the same. 

For several years I have been interested in collecting items of interest 
relating to various occupations: and perhaps a few facts regarding some 
of the best, and yet in reality least known, may be of interest. 

It should, however, be remarked that the term "extra hazardous," as 
applied to an occupation, has so frequently been used to imply extra lia- 
bility to accident, that we are apt to be misled by it ; for it will be at once 
evident that an occupation subjecting to possible accident, is frequently 
otherwise conducive to health, and that one enjoying immunity from acci- 
dent may be the source of an enlarged mortality ; mariners of the former 
and clerks of the latter class are familiar examples. 

It would indeed be an inquiry of general interest, could we decide to 
what extent the healthfulness of an occupation can counterbalance the 
tendency to mortality from accident. 

The following facts relate chiefly to mariners, railroad employes, and 
Toyagei's after health, pleasure, and profrt. 

Before presenting the main facts upon which our conclusions are based, 
we would call attention to a brief table of general mortality for compari- 
son or reference. 

Table of Death-rates in various parts of the World. 

Standard of hygieiiists 17 to 1000 

Average in United States 22 to 1000 

" ^ " England 21 to 1000 

" Cities of United States 2S to 1000 

" " " England 22 to 1000 

In tenement houses in cities . . . . . . 52 to 1000 

In healtliy rural districts 12 to 1000 

jVb/c. — In estimating tlie extra tendencies to mortality, the last two items are 
significant in their juxtapo-ition. 



1870.] HoLPEN, Mortality of Mariners, Railroad Men, etc. 103 

To this table may be appropriately annexed the death-rate in a few 
specific localities, say for the year 1873. 

New York . . . . 32 to 1000 Brooklyn .... 28 to 1000 

Boston . . . . 30 " 1000 St. Louis . . . . 21 to 1000 

Troy 34 " 1000 Chicago . . . . 27 to 1000 

Hoboken . . . . 39 " 1000 Baltimore .... 25 to 1000 

Philadelphia . . .2(3" 1000 San Francisco . . 17 to lOdO 

Memphis, Tenn 4(j to lOdO (yellow fever year) 

In following year (1874) . . . 23 to lOdO 

In contrast to this, and especially as bearing on the risk to travellers, of 
a foreign residence, raay be cited : — 

Bombay . . . . 29 to 1000 Calcutta . . . . 25 to 1000 

The highest death-rate I have found recorded, is of Valparaiso, Chili, 
viz., 66 to 1000. 

The figures relating to Bombay and Calcntta, although so unexpectedly 
in contrast with western countries, are oflficial and believed to be correct, 
referring, however, to a population chiefly native. 

Compare the following differences among ordinary every-day occupa- 
tions: thus, in London, the death-rate among — 

Shopkeepers, merchants, and butchers is . . . . 16 to 1000 

Shoemakers, blacksmiths, carpenters, and watermen . . 23 to 1000 

Clerks, porters, messengers, tailors, and painters . . 2(5 to 1000 

Policemen, cabmen, and hostlers 28 to 1000 

Laborers, masons, and bricklayers . . . . . -15 to 1000 

First, regarding Mariners.^ — The number under my own observation 
for a period of ten years has been 523, and the mortality rates 111 to 
1000. 25 per cent, of the deaths among them arose from accidental 
causes, growing out of occupation ; deduct from this the percentage of 
liability to accident existing in the adult population at large, say 2 per 
cent., and we have 23 per cent, of the deaths as representing the actual 
extra hazard of that class ; in other words, an extra death-rate of 27 to 
1000. 

The rate obtained from the records of the Travellers' Insurance Com- 
pany of Hartford up to 1S68, was on mariners, from causes growing out 
of occupation, only 4 to 1000, yet by a later compilation and experience 
this varied on different classes from 6 to 29 per 1000. 

Contrary to expectation, and a point of great interest, officers do not, 
either in the naval or mercantile marine, exhibit a more favourable mor- 
tality than the men ; for by the report of the insurance company already 
alluded to, pilots and officers of vessels show a death-rate from their occu- 
pation of 8 to 1000, while seamen give but 4 to 1000. For the figures 

' Neison, Vital Statistics. 



104 HoLDEN, Mortality of Mariners, Railroad Men, etc. [Jan. 

relating to the navy, reference may be made to the table on the following 
page. 

Having alluded to a usual rate of mortality from accident, it may be of 
use to give the following figures : — 

Of 1 1,318 males who died in New York city in 1866, 376, or 30 to 
1000 of the deaths, were from violent causes, being, in fact, but 3 percent- 
of the deaths. 

Of 2801 deaths of males in Brooklyn during the same period and from 
similar causes, 65, or about 2^ per cent, of the deaths, were from such 

cause. 

In the experience of The Mutual Benefit Life Insurance Company of 
Newark, up to 1868, 8 per cent, had been from violent causes. 

Unfortunately, no use can be made of the last census of the United 
States in ascertaining the death-rate of sailors at large shipping from our 
ports, inasmuch as deaths among them seem not to have been recorded. 
As the number was over 56,000 for the census year, such a record would 
have proven of great value in this inquiry. 

By English returns (Neison, p. 137), the unfavourable character of this 
class of occupation, as indicated above, seems to be verified, the mortality 
being 86 per cent, above that of the population of England and Wales. 

Further than this, out of 270 deaths in the class, 105, or less than one- 
half, were from natural causes. 

00 per cent, of the deaths arose from the accidents of occupation. 

In number, 62 were lost with their vessels, and the remainder were 
drowned, washed overboard, etc. 

The influences that thus render the mercantile marine service so unfavour- 
able may perhaps be thus enumerated, viz. : — 

Shipwrecks, fire, privation and exposure, improperly ventilated cabins, 
sickly ports, changes of climate, licentiousness in, and disease out of it — 
almost always without proper medical care, and perhaps, more frecpiently, 
improper treatment by the mate or captain, who must do the duty of 
physician and surgeon. The hazard, however, differs widely according to 
circumstances. 

Compare for a moment the condition of the sailor in the bunks of a 
coasting or fishing vessel under the combined influences of charcoal fire, 
frequently respired air, and stale tobacco smoke — with that of the naval 
seaman, and the following remarks will be the more significant. Instead 
of a mortality of 111 to 1000, we find (taking the years before the war, 
as excluding casualties of battle) but 20 to 1000. As this, however, 
includes both officers and men, we may be more explicit : thus, among offi- 
cers it was 25 to 1000 ; among men H> to 1000. 

The following are the tables : — 



1876.] IIoLDEN, Murtalily of Mariners, Railroad Men, etc. 



105 



I. Table showing as nearly a.s jjossible the average strength of the navy, 
including officers, men, etc., with total number of deaths for each 
year from 1850 to 18G6, inclusive. 

1850 
IS.'il 
li?52 

1S54 
1655 
lS5(j 
1S57 
1858 
1859 
1860 
IStil 
1862 

18G4 
18G5 
18(36 



II. Statement of 
icith number 

1850 . 

1851 . 

1852 . 

1853 . 

1854 . 

1855 . 
185G . 

1857 . 

1858 . 

1859 . 

1860 . 

1861 . 
Ib62 . 
1863 . 
1S64 . 

1865 . 

1866 . 



age streugth. 


Deaths 


9,0)57 


129 


9,063 


65 


9,103 


81 


9,051 


84 


8,975 


193 


8,982 


115 


9,962 


119 


10,163 


123 


11,895 


155 


11,895 


115 


11,000 


121 


20,000 


178 


25,905 


575 


40,000 


1048 


43,787 


1373 


32,641 


930 


17,193 


310 



Commissioned and other Officers in the U. S. Navy, 
of deaths from 1850 to 1866, inclusive. 



No. of com. officers 

. 822 

. 826 

. 827 

. 829 

: 827 

. 815 

. 961 

. 945 

. 926 

. 973 

. 968 

. 959 

. 1905 

. 2423 

. 2835 

. 3898 

. 1609 



Deaths. 

25 

19 

21 

24 

16 

33 

25 

37 

20 

22 

27 

33 

54 
100 
106 

62 

39 



warrant offic. 
676 
659 
675 
682 
672 

446 

465 

537 

530 

616 

664 
1851 
2580 
3646 
3831 
1591 



Deaths. 
16 
11 

7 
21 
12 
26 

6 

7 
11 

i 
10 
10 
21 
86 
73 
47 
30 



It will be observed that naval officers do not seem to sliow any more 
favourable mortality, as compared with the seamen, than was indicated as 
belonging to the officers of the mercantile marine. 

The deductions from the above table for the years of the war, or rather 
for the years during which the navy was more particularly engaged, will 
show in some measure the liabilities of battle. 

Thus, while during peace the mortality may be put down as 1 to 48 



100 HoLDEN, Mortality of Mariners, Railroad Men, etc. [Jan. 

(20 to 1000), the war increased it to 1 to 36 (28 to 1000); officers, before 
1 to 40 (25 to 1000), decreased to 1 to 44 (24 to 1000), owing to the 
large number of appointments made in 1865 in anticipation of a pro- 
longed war, and after battles had become infrequent. 

The mortality, among seamen alone, before the war (19 to 1000), in- 
creased to 1 to 32 (31 to 1000). 

The experience of the Travellers' Insurance Co. of Hartford, recently 
tabulated and kindly furnished by the actuary of that company, enables 
me to present the following special excerpta bearing upon the occupation 
under consideration, viz. : — 

Captains of lake and sea vessels exhibit a mortality of 10 to 1000 from 

accidents of occupation only. Years of life exposed .... 466.7 

Captains of river steamers 6 to 1000. Years of life . . .i . 148.25 

Captains of tugboats 29 to 1000. " " .... 34.3 

Clerks of steamers 7 to 1000. " •< .... 251.2 

Engineers of steamers 25 to 1000. " " .... 70.7 

It is, however, to be remarked that the larger figures indicating the risk 
upon captains of tugboats and engineers of steamers may be due to the 
smaller number under observation ; for, by another record of the same 
company for a single year, covering 97,840 lives, pilots and officers of 
vessels show a mortality from accident of but 8 to 1000; seamen 4 to 
1000. 

Conchision xoith reference to Mariyiers. — While specific Investigation 
does not to the fullest extent corroborate the startling exhibit of the 523 
mariners at first alluded to, yet when we reflect that even eight, ten, or 
twelve deaths to one thousand are to be added to the expectation of mor- 
tality, the extra risk of the occupation will be apparent. There is, how- 
ever, reason from the above figures and investigation to believe that twelve 
or even twenty extra deaths will not cover the actual extra mortality. 

It should, however, be noted that this ruling does not apply to either 
officers or seamen of the navy, whose rate of mortality /ro?n all causes 
does not exceed that of the cities of the United States. 

Note. — Possibly officers of established lines of steamers may also' be 
excej)ted. 

Railroad Employes. — In estimating the mortality among railroad men, 
the statement already made that the healthfulness of an occupation may 
offset the danger incident thereto is peculiarly applicable, for as a class 
they are exceptionally healthy. The very nature of their occupation, in 
the open air, suggests this, and experience confirms it. 

By the returns of the last census, we may obtain an idea of the al)stract 
tendency to death from accident before proceeding to ascertain the actual 
death-rate ; the returns not being of a sufficiently explicit character to 
enable us to draw complete deductions. Thus the number of deaths from 
railroad accidents and injuries for the year 1870 was 1461, including 



1876.] HoLDEN, Mortality of Mariners, Railroad Men, etc. 1(7 

passengers, eraployds, and outsiders. The whole number of railroad em- 
ployes was 154,027 (excluding clerks). Now, if the whole number of 
deaths had been among employefi alone, the rate would have been a special 
one of but 9.5 to 1000, a surplus of risk probably more than balanced by 
the freedom from other sources of mortality. But the mortality given 
included persons upon the track, passengers, and outsiders generally, and 
would probably not amount to more than 3 to 1000 for railroad employes 
alone. In order to have a standard of comparison, it may be of interest 
to note that out of 40,000 selected lives to the records of which I have 
access. 

The death-rate anions^ adults over 30, with consumption in the family, 

was IS to 1000 

Same with no consumption in family . . . . . . . ."j to 1(H»0 

Rate among those under 30, with consumption in the family . . 38 to 1000 
Same without 10 to 1000 

Still drawing upon the same source, there appears a death-rate among 
engineers and brakemen of but 15 to 1000, and chiefly from causes foreign 
to occupation. Railroad conductors 22 to 1000, with the same fact true 
of them. 

That we may not be hasty in drawing conclusions from a too meagre 
array of facts, and to avoid confounding the unsafe among railroad em- 
ployes with the safe, we remark that the danger of death by accident is by 
no means equally divided among engineers, brakemen, conductors, and 
others termed trainmen, and, as will be seen by reference to the experience 
of the Hartford Insurance Company, the difference may be considerable. 
This difference is especially noticable between brakemen of passenger and 
freight trains. 

After much patient investigation, I have introduced the railroads of 
New York State, as alfordinga good and condensed example of the roads 
of this country, and appended the experience of those of England as 
presented in the report of the Board of Trade of Great Britain. The 
former, fifty-six in number, include as great a variety in respect to 
management and Success, from t-lie most reckless to the most carefui, as 
can be found. 

In 1868 the number of miles of road operated by steam was 4567.99; 
operated by horse-power, 315. 

Although now inquiring only into the liabilities of railroad employes, 
we present the following condensed summary, which includes passengers 
and outsiders, that the relative liabilities of such persons may at the 
same time be seen. 

In 1868 the average number of passengers carried to each one killed 
was 236,337. In Great Britain, according to the reports referred to, 
only one passenger out of 2,312,633 is said to have been killed ; a com- 
parison anything but favourable to American railroad management. In 
1867 the figures stand 1 to 1,336,728; and, in 1866, 1 to 1,073,804. 



108 



HoLDEN, Mortality of Mariners, Railroad Men, etc. [Jan. 



Number of passengers killed 
" " " injured 

" " employes killed 
" " " injured 

" " others killed 
" " " injured 

Total killed . 
" injured 



Same on roads opei-afed by horse-poxver 



Passengers killed 
" injured 

Employes killed 
" injured 

Others killed 
" injured 



Total killed . 
" injured 



As already stated, the ratio of killed 



186f). 


1S67. 


]S68. 


17 


13 


78 


107 


70 


173 


70 


67 


77 


6tJ 


65 


100 


124 


95 


147 


60 


68 


86 


211 


175 


302 


233 


203 


358 


se-poivei\ 




1866. 


1867. 


]S68 


13 


20 


3 


35 


49 


65 


1 


3 


1 


1 





1 


20 


19 


9 


13 


19 


24 


34 


42 


13 


49 


68 


90 



among passengers to the whole 



number transported was, in 1866, 1 to 1,073,844. 

The rate among employes was, killed 

" " " " injured 

In 18 1.7, passengers 

" employes killed 

" " injured 

In 1868, passengers 

" employes killed 

" " injured 



1 to 59 (17 to 1000) 
1 to 63 (16 to 1000) 
1 to 1,336,728 
1 to 6ij (15 to 1000) 
1 to 67 (15 to lOOU) 
1 to 2,312,533 
1 to 58 (17 to 1000) 
1 to 45 (22 to 1000) 



An item of interest to passengers may be worth stating, viz., that the 
average number of miles of travel necessary to consummate the maiming 
or slaughter of each passenger was, in 1868, 2,621,826. In 1866 it was 
Considerably more, viz., 6,387,523 ; in 1867 still more, 7,909,936. 

We have referred to the comparative danger experienced in the various 
branches of railroad employment. To reduce this relation to figures, it 
would be necessary to ascertain the relative frequency of accident and 
death in each branch. 

The incompleteness of official reports, and the jealous fears of certain 
corporations that all publicity in reference to accidents might operate to 
their individual disadvantage, renders aecurate details impossible among 
the railroads under consideration. A fair approximation, however, has 
been derived from information courteously furnished by a few companies, 
and by the following method, viz. : The Erie Railway exhibits in its offi- 
cial reports a total number of deaths from accidents for the years 1867-8, 



15 " 


22 


4 " 


2 


1 " 


4 


4 " 


5 


4 " 


1 




10 



18TG.] HoLDEN, Mortality of Mariner.--, Railroad Men, ete. 109 

of 104; and of injured persons, 15T. Of this nunihcr, 74 were employes; 
115 passen.u^ers ; and 72 outside persons accidentally upon the traek. 
The employes were thus divided : — 

Conductors 2 killed, 1 injured. 

Brakf'inen ...... 

Firemen ...... 

Engineers ...... 

Switchmen ..... 

Trackmen and labourers 

Others . 

Estimating these with a view to the usual number of each required or 
commonly employed ou a road, viz., conductors 1, engineers l.o, firemen 
1.5, brakemen 3, an approximation may be made toward a fair arrange- 
ment. 

One more prominent road may be cited as an example, viz., the Hudson 
River Road (years 1867-68) :— 
Total killed and injured 111. 

Of these, 38 were employes, and 13 passengers. Of the employes 
there were — 

Conductors ...... killed, injured. 

Engineers ....... 1 '" " 

Firemen " 1 " 

Brakemen ....... " 4 " 

Otiier employes 12 " 20 " 

(These two roads will probably suffice in detail.) 

The largest proportion of accidental injuries and deaths on the last- 
mentioned road arose from coupling and uncoupling cars — a remark appli- 
cable to other well-managed roads. The deductions from the experience 
of the fifty-six roads of New York State enable us to rate the employes in 
the following order, as regards liability to accident, viz., freight brake- 
men, passenger brakemen, firemen, engineers, conductors, switchmen, track- 
men, and labourers. 

If we now compare the mortality among the railroad employes of this 
country with that of EngMind, as presented in the following report of the 
English Board of Trade, the difference appears incredible, and would seem 
to present American "fastness" in an unenviable light, or reflect severely 
upon our railway management. 

Return of English li.R. Companies by report of the Railway Depart- 
ment of the Board of Trade. 

Death-rate among — 

Eueine drivers 1 to 220 or 4..') to 1000 



Stokers 
Guards 
Porters 
Other servants 



1 to 144 " 6.9 to 1000 

1 to 117 " 8.5 to 1000 

1 to 602 " 1.6 to 1000 

1 to 546 " 1.8 to 1000 



110 



H OLDEN, Mortality of Mariners, Railroiul Men, etc. [Jan. 



1 to 171 or 5.8 to 1000 
1 to 13(J " 7.3 to 1000 
1 to 149 " 6.7 to 1000 
1 to 1083 " .09 to 1000 
1 to 1102 " .09 to 1000 



Ratio of injury — 
Engine drivers 
Stokers .... 

Guards .... 

Porters .... 

Other servants 

The following is from the seventh annual report of the Conductors' 
Life Insurance Association of St. Louis : — 

Issue of policies for six years ...... 5868 

Forfeited 2601 

Surrendered .......... 1370 

Died . . 148 Killed . . 70 Disabled . 33 

Estimating approximately from these figures, and with the assistance 
of definite statistics of the company for the year ending August, 1874, we 
have an average yearly death-rate among conductors of 25 to 1000, and a 
rate from accident 11 to 1000. 

For the single year 1874, this is much better. Thus, total death-rate 
20 to 1000; from accidents, 5.8 to 1000. 

The e.xperience of the Travellers' Accident Lisurauce Company of 
Hartford, among railroad men, appears to be of great value, and, as 
newly tabulated, is as follows : — 

(Rate from accidents of occupation only) — 

Locomotive engineers (2(i72.9 years of life exposed) . 9 to 1000 

Passenger conductors (3133.6 years of life exposed) . 1 to 1000 

Freight conductors (638.9 years of life exposed) . . 7 to 1000 

Express tiiesseugers OS to 1000 

Freight agents . . . . . . . . 1 to 1000 

Mail agents 1 to 1000 

Baggage masters . . . . . . . . 3 to 1000 

Passenger brakemen (638.9 years of life exposed) . to 1000 

Freight brakemeu. . 32 to 1000 

Car repairers and track labourers . . . . . 3 to 1000 

By a former exhibit of the same company, covering only a single year, 
but drawn from nearly a hundred thousand lives, the following is the 
rate : — 

Railroad freight brakemen 22 to 1000 



6 to 1000 
9 to 1000 
5 to 1000 
3 to 1000 

Bv collatin<r the al)ove 



" passenger brakemen 

" engineers and firemen 

" conductois and baggage masters 

" Employes generally 

Conclusions regarding Railroad Employe 
statements it will be seen — 

1. That the actual death-rate is less tlian among many occupations 
considered more favourable to life. 

2. That i\\Q proportion of deaths from the accidents of their occupation 
is considerable, but shows a balance favourable to the general healthful- 
ness of the occupation. 



187C.] HoLDEN, Mortality of Mariners, Railroad Men, etc. 



Ill 



3. That the actual e.xtra hazard lies among freight ijrakeinen, but is 
yet less than that found to e.xist in the safer occupations alluded to. 

Voyagea for Health, Pleasure, or Business. — In the endeavour to 
ascertain the degree of special risk involved by this class of persons, so 
much depends upon the circumstances of each individual case that statis- 
tics can hardly be made available. Still, it may be asserted that it is a 
compound risk simply of transportation and climate. Of the voyages for 
health and pleasure, the risk of transportation is chiefly, perhaps only, to 
be considered; for no travellers are so readily turned back from unhealthy 
or dangerous localities as these, and the very objects of their journey pre- 
clude any exposure to unnecessary dangers of climate. With regard to 
the special risk of transportation, the conclusions above presented touch- 
ing railroads and the dangers of the sea, will enable us to judge. Surely 
the ratio will not be greater than that borne by the one voyage of the 
traveller to the scores made by the mariner, and both this and the slight 
one from change of climate, must be to great extent balanced by the 
benefits of the voyage. Indeed, voyages for health or pleasure can hardly 
be other than favourable to the prolongation of life. With the class of 
travellers, however, who are seeking profit, the case is different, and the 
extra risk involved may be very great both from transportation and cli- 
mate. What the actual risk may be in some localities can perhaps be 
inferred by examining the following concerning armies in time of peace, 
and virtually among selected- lives. First, for certain parts of the United 
States (from medical statistics of the U. S. Army, 1855 to 1859 inclu- 
sive). The sickness ratio is also given for comparison : — 





Annual rate 


Ratio of death 


Ratio of death 


Mortality 


u. s. 


of disease to 




to 


to 


exiusive of 




strength. 


strength. 


number ill. 


cholera. 


Coast of New England 


1.7.') to 1 


8.8 to 1000 


1 to 196.20 




New York Harbor 


8.18 to 1 


21 


to 1000 


1 to 151.23 


1.84 p. c. 


West Point 


4.«2 to 1 
l.SO tol 


4 

10 


to 1000 
to 1000 


1 to 1088.0 
1 to 164.77 


0.39 p. c. 


Region East of Great Lakes 


Region of the Great Lakes 


2.18 to 1 


13 


to 1000 


1 to 159. 


1.31 p. 0. 


' Region west of Great Lakes 


2.27 to 1 


14 


to 1000 


1 to 162.8 


1.19 p. c. 


Middle Atlantic Region ... 


2.23 to 1 


16.8 to 1000 


1 to 133.11 




Middle Interior East 


3.18 to 1 


15,7 to 1000 


1 to 201.83 


1.49 p. c. 


Newport Barracks, Ky 


2.78 to 1 


35 


to 1000 


1 to 78.25 


2.93 p. c. 


Middle Interior West 


2.64 to 1 


34 


to 1000 


1 to 77. 


2.24 p. c. 


South Atlantic Region 


2.65 to 1 


27 


to 1000 


1 to 97. 


1.73 p. c. 


South Interior Region East 


3. tol 


47 


to 1000 


1 to 66.12 


4.05 p.c. 


South Interior Region West 


3.37 to 1 


24 


to 1000 


8 to 139.30 


2.2 p.c. 


Atlantic Coast of Florida.. 


3.51 to 1 


24 


to 1000 


1 to 143.35 




Int. and Gulf Coast Florida 


4.90 to 1 


30 


to 1000 


1 to 162.28 




Southern Frontier of Texas 


3.59 to 1 


55 


to 1000 


1 to 64.48 


4.96 p.c. 


! Western Frontier of Texas 


3.08 to 1 


32 


to 1000 


1 to 94.13 


1.96 p. c. 


New Mexico 


2.61 to 1 
2.10 to 1 


21 

18 


to 1000 
to 1000 


1 to 121.50 
1 to 116.27 




California (Southern) 


California (Northern) 


2.82 to 1 


46 


to 10(10 


1 to 60.83 


2.56 p.c. 


Oregon & Wasliington Ter. 


2.30 to 1 


9 


to 1000 


1 to 234.7 




Utah 


1.84 to 1 


8 


to 1000 


1 to 225.52 





112 HoLDEN, ^rortality of Mariners, Railroad Men, etc. [Jan. 



From this table it will he seen to what extent the locality affects the 
amount of disease and the rate of mortality, varying in regard to the 
former from 4.90 to 1 (interior of Gulf Coast of Florida) to 1.80 to 1 
(region east of the great lakes) ; and, in regard to actual mortality, vary- 
ing from 0.39 per cent. (West Point) to 4.96 per cent, (southern frontiers 
of Texas), exclusive of cholera. Yet it will also be noted that it is not 
locality per se, which is of chief importance, but locality without accli- 
mation. This influence of locality, without acclimation, is strikingly 
exhibited in the experience of the British Army at home and abroad, and 
especially when compared in the latter instance with native troops of the 
same localities. (Report of British Sec. of War; Report of Dr. Bal- 
four, Assistant Surgeon to the Madras Army; and Journal London 
Statistical Sue, vol. viii.) 

British Regiments at home, animal mortality 
New South Wales, 

Cape of Good Hope, " " 

Nova Scotia, '* " 

M.Uta, " " 

Canada, " " 

Gibraltar, " " 

Ionian Islands, " " 

Mauritius, " " 

Bermuda, " " 

St. Helena, " " 

Bombay, " " 

Ceylon, " " 

Bengal, " " 

Jamaica, " " 

Bahamas, " " 

Sierra Leone, " " 

Native troops — 

Maltese at Malta 9.0 per 1000 

Hottentots in Africa 12.5 " 

Native Bengal Army ...... 13.0 " 

Native Madras " 15.0 " 

Native Ceylon " ...... 25.8 '• 

The above figures, while somewhat meagre for general use, are yet ade- 
quate to establish the position we assume, viz., that voyagers for profit 
whose business relations necessitate continued stay may be at an extra 
hazard of life just in pro[)ortion to the character of the climate involved ; 
but that, as with the other classes, the question of transportation by sea 
or land is not of necessity important. 

The following appear to be justifiable conclusions : — 
1st. That voyagers for healtii or pleasure are not of necessity at extra 
risk of life. 



y . . 15. n pe 


1000 


. 14.1 


" 


. 15.5 


i( 


. 18.0 


i( 


. 18.7 


" 


. 20.0 


u 


. 22.1 


(( 


. 28.3 


(( 


. 30.5 


" 


. 32.3 


" 


. 35.0 


" 


. 55.0 


•' 


. 57.2 


f( 


. 63.0 


" 


. 143.0 


u 


. 200.0 


l( 


. 483.0 


" 



1876.] LiPi'iNCOTT, Traumatic Hypertrophy of Fill j(ci'. 113 

2d. Tliat voya,a;er.s for Inisiiicss or profit are at such extra risk only so 
far as the character of the climate, the leuf^tli of stay, and question of 
acclimation are concerned. 

The general deductions from the facts adduced may he thus epito- 
mized : — 

1st. The occupation of seafarincr men is more hazardous tlian is gene- 
rally supposed. 

2d. Railroad employes (excepting l)rakeraen) are as much as, and per- 
haps more, likely to attain long life than other classes of men, and — 

3d. That travellers, unless when too long- delaying in unhealthy climates, 
and so becoming residents, do not especially increase their liability to 
death. 



Art. XI. — Remarkable Case of Traumatic Hypertrophy (including 
Elongation) of Digital Phalanges. Reported by J. A. Lippincott, 
M.D., Late Resident Physician at the Pennsylvania Hospital. 

The following case was admitted into the Pennsylvania Hospital Feb. 
12, 18Y5, under the care of Dr. William Hunt, Visiting Surgeon, by whose 
permission it is reported. 

Thomas H., a healthy labourer of healthy extraction, ast. 25, applied 
for admission on account of an hypertrophied condition of the ring finger 
of the right hand. His mother states that, when he was two years old, u 
large stone with which he was amusing himself, fell on his finger, injuring 
the end of it severely. From that time, that portion of the digit began 
to enlarge. One year afterwards the affected finger was bent violently 
backwards in a fall, and subsequently the whole finger steadily increased 
in size until the hand ceased to grow. A rigid cross-examination elicited 
the positive and reiterated assertion that the hand was perfectly natural 
at birth and up to the time of the accident. 

On admission the patient is five feet nine inches in height, and fairly 
well proportioned. The following table shows the measurements of the 
affected finger, as compared with those of the corresponding finger of the 
other hand : — 

Normal Afi'ected 

Finger. Finger. 

Length of finger 4 in. 5 in. 

" of proximal phalanx .... If* in. ^i^g in. 

" of middle " .... I/5 in. l}f in. 

" of distal " .... 1 in. l/g in. 

Circumference of proximal phalanx in centre . 2y\ in. 3j'g in. 

'' of proximal phalanx at distal end 2jJ. in. 3|^ in. 

" of middle phalanx in centre . 2j\in. Sy^g in. 

" of middle phalanx at distal end . 2|'g in. Sj^'g in. 

" of distal phalanx in centre . 2j'g in. B^^'g in. 

Greatest width of nail A in- (fin. 

Length of nail (cut close) . . . . ,^d in. \l in. 

No. CXLI — Jan. 1876. 8 



]14 LiPPiNcoTT, Traumatic Hypertrophy of Finger. [Jan. 

The finger is natural in colour, smooth to the touch, and, as will be 
seen by reference to the table, pretty uniformly enlarged. The condyles 
are disproportionately prominent. Two knobs project from the sides of 
the middle phalanx. The lateral diameters are everywhere proportionately 
greater than the dorso-palmar. The finger is straight, with the exception 
of a slight fixed flexion at the last articulation. There is perfect motion 
at the metacarpo-phalangeal articulation, and slight mobility at the two 
others. The metacarpal end of th6 proximal phalanx projects, from its 
enlargement, into the palm of the hand, and the cuticle over it is much 
thickened. The soft tissues seem somewhat thinner than on the other 
finger. Sensation is normal, except when the finger is subjected to cold, 
which readily afi'ects it (particularly the extremity), and gives him con- 
siderable distress at times. This discomfort, as well as the annoyance and 
inconvenience which he experiences from the presence of so unwieldy a 
member while at work, have induced him to have the finger removed. 

The middle finger of the same hand was also injured at the time of the 
first accident. There is no hypertrophy, but there is a slight lateral flexion 
with subluxation at the last joint, the extremity inclining towards the 
index finger. 

Dr. Hunt amputated at the metacarpo-phalangeal articulation. The 
operation was followed by rather active inflammation, with moderately 
profuse suppuration. These symptoms, however, gradually subsided, and 
the patient was discharged cured April 12, 18t5. 

On examination of the finger after removal, the digital artery on the 
radial side was found to be much enlarged in calibre, and its coats very 
considerably thickened, but there was no evidence of atheromatous or 
other degenerative change. 

The specimen was examined Ijy Dr. Morris Longstreth, Pathologist and 
Curator to the Hospital, from whose report the following extract is 
taken : — 

" An incision, made through the skin on the palmar surface of the first 
and second phalanges, shows the cutaneous tissues to be thicker than is 
normal; about in the proportion to the increased size of the finger. The 
adipose tissue is as usual. The sheath of the flexor tendons is unusually 
thick and firm. The combined flexor tendons are markedly thickened, 
measuring at the base of the first phalanx two inches in circumference. 
They are received into a correspondingly capacious groove on the palmar 
surface of the bone, the antero-posterior diameter of which in the median 
line ranges between three-eighths and five-eighths of an inch. The poste- 
rior surface is convex from side to side so that a transverse section of 
the bone is crescentic in outline. The aponeurosis of the extensor com- 
munis digitorum is enlarged; apparently in proportion to the general 
hypertrophy of the finger. The first phalanx was divided longitudinally, 
one-half being renioved for examination microscopically. 

" After careful microscopic examination of section of the bone, every 
portion appeared normal, both as to the size and to the arrangement of its 
minute anatomy." 

Rema7'ks. — This case is interesting, because traumatic elongation of 
the fingers is exceedingly rare, if, indeed, it has ever before been described. 
Annandale, in his interesting work on llalformations, Diseases and In- 
juries of Fingers and Toes, p. 5, relates two congenital cases of elongation 
of the fingers, and alludes to several others. CarVmg (3led.-C'hir. 2'rans- 



1876.] LiPPiNCOTT, Traiiinatic Hypertroi)liy of Finger. 115 

actions, vol. xxviii. p. 337) inciitions six cases, one of which came under 
his own observation. Dr. Ewald, of Berlin ( Virchoio^s Archiv, Bd. 5(i, 
s. 421) describes a case of elongation of the index and middle fingers of 
the left hand. Adams, of Dublin, relates a case in which the middle finger 
of the left hand was eight inches long, while the corresponding finger of 
the other hand was three and a half inches (quoted by Friedberg in Vircli. 
Archiv, Bd. 40, s. 373). Friedberg, in the same paper, refers to a case of 
Meckel's, of elongation of the right forefinger; but all of the above-men- 
tioned cases, liiie those mentioned by Annandale, were congenital. Roki- 
tansky {Pathol. Anat., vol. iii. p. 122) remarks : " Sometimes elongation 
is observed only in particular fingers, toes, or limbs ;" and adds that it 
may be congenital or come on after birth ; but there is nothing in the 
context to warrant the supposition that he had met with non-congenital 
lengthening of the fingers. Prof. Friedreich, of Heidelberg {Virch. 
Archiv, Bd. 43, s. 84) relates a very interesting case of non-congenital 
elongation of the phalanges of the fingers, associated with hypertrophy of 
various other bones, which began at the age of eighteen ; but in this case 
there was no history of an injury, nor, indeed, was there any assignable 
direct cause. 

The fact of bones sometimes undergoing elongated hypertrophy does 
not seem to have occurred to the older writers. The comprehensive and 
valuable works of Boyer, Lobstein, and others, while they treat of hyper- 
trophy of osseous tissue, contain no allusion to increase in length. But 
very brief reference is made to the subject in the modern standard works 
on surgery.' Stanley, who seems to have had more experience of elonga- 
tion of bone than perhaps any other writer, and to whom Paget, in his 
Surgical Pathology, vol. i. p. 83, acknowledges his indebtedness for most 
of his information on the subject, says: " Long bones are often increased 
in thickness, but rarely in length."- He relates instances of elongation 
of the femur, tibia, and fibula, and states that talipes and curvature of 
the spine, as well as great inconvenience in walking, may I'esult from this 
form of hypertrophy in the lower fimbs. He and other writers describe a 
peculiar form of curvature of the tibia arising as a consequence of length- 
ening of this bone, while the fibula remains of normal length, and the 
unitiug ligaments refuse to yield. 

As to the etiology of non-congenital elongation, all authors agree that 
it always takes place before the natural growth of the osseous tissue ceases. 
Prof. Friedreich's case, already referred to, makes it probable that family 

' In view of the comparative scantiness of literature on the subject, the extra- 
ordinary and uncliallenged assertion of one of tlie members of the Patliolcgical 
Society of London to the effect that real elongation of bone " was not described 
anywhere in surgical works," is perhaps excusable. {Vide Brit. Med. Journal, 
Feb. 20, 1875, p. 257.) 

2 Diseases of the Bones, Phila., 1S49, p. 25. 



IIG LippiNCOTT, Traumatic Hypertrophy of Finger. [Jan. 

predisposition has a causative influence, as one of the patient's brothers 
was very similarly affected. Volkmann (Pitha und Billroth's Handbuch 
der Ghiria-gie, Bd. ii. Abth. ii. s. 350) assigns as a cause the removal of 
physiological pressure, and gives, as an example, lengthening of the ra- 
dius after dislocation from its connections with the humerus. Broca 
{Des Aneuriames, Paris, 1856, p. 76) relates a case of aneurismal varix of 
the thigh, three centimetres below Poupart's ligament, which was followed 
by an increase of three centimetres in the length of the limb, the femur 
being one centimetre and the tibia two centimetres longer than the corre- 
sponding bones of the other limb. In Mr. Holden's case, mentioned by 
Paget (Surgical Pathology, vol. i. p. 87 j, the elongation, which affected 
the femur, was compensator ij, and was equal to the shortening of the 
tibia and fibula, which were atrophied from necrosis. 

In the great majority of cases the disease owes its origin to specific or 
non-specific inflammation and ulceration of the bone, or of the neighbour- 
ing soft parts. Erichsen {^Science and Art of Surgery, vol. ii. p. 158; says : 
" I have seen, as the result of chronic osteitis, the tibia from one and a 
half to two inches longer than its fellow." Langenbeck states that morbid 
changes which give rise to irritation and hypera^mia of the osseous tissue, 
may lead to increase in length as well as in thickness of bones.* In all 
of Stanley's cases, with one exception, there were numerous chronic 
ulcers over the affected bone. The case excepted was that of a strumous 
patient who was afflicted with an abscess of the thigh. When the dis- 
charge from the abscess ceased, the tibia of the opposite leg began to 
enlarge in every direction, and four years subsequently it was found to be 
an inch and a half longer than the tibia of the other limb. In a case 
described by Humphry {Jled.-CJiir. Transactions, vol. xlv. p. 300) there 
was a sinus on the inner side of the left thigh, communicating with the 
femur, which was one inch longer than the femur of the riglit side. 
M. Guibout exhibited before the Sociele Aledicale des HOpitaux, a patient 
suffering from tertiary syphilitic maiyfestations, whose right leg had 
undergone lengthening to the extent of two-thirds of an inch.^ Gross ' Sys- 
tem of Surgery, 5th edit., vol. i. p. 885) mentions a case of lengthening 
as well as of thickening of the bones of the leg and foot, the result of exten- 
sive ulceration. Yolkmaun (in Pitha und Billroth's Handl)uch der Ghi- 
rurgie, Bd. ii. Abth. ii. s. 296) refers to a case described by Weber, in 
which, after necrosis of the tibia and fibula, these bones were six inches 
longer than those of the other limb. 

Sometimes it is difficult, if not impossible, to arrive at any adequate 
explanation of this form of liyperirophy. 

' Quoted iu Erit-h^en's Surgerj, vol. ii. p. 179. 

2 Quoted from LUiiion Medicale iu Bosiou Med. aud Surg. Jouru., July 4, 1S72, 
p. 15. 



187'i.] TiiPi'iNCOTT, Tnuimatic Tlypertropliy of Finger. 117 

Benjamin W., net. 21, was iidMiitted into the Pennsylvania Hospital in 
I>ecember, 1874, complaining of ]>ain in the right hip-joint. He was 
supposed to be suffering from morbns co.xarius and curvature of the spine. 
Careful e.xamination excluded the idea of disease of the joint, and the 
curvature, which was easily made to disappear, was found to be owing to 
an elongation of the femur to the extent of an inch and a quarter. The 
patient stated with great positiveness that he had no deformity of any 
kind before the age of sixteen. 

In this case there was apparently no hereditary or acquired ]iredisi)osi- 
tion to account for the abnormal growth, and there was no history of 
injury or of any other exciting cause. 

The minute pathology of elongation, as distinguished from other forms 
of hypertrophy of bone, has not attracted much attention. Rindfleisch, 
who stands pre-eminent in this field of study, does not allude to it. Tiie 
recently published lectures of Wilks and Moxon also do not mention the 
subject. Humphry attributed the lengthening in his case to the disease 
in the lower part of the shaft of the femur acting as a stimulus to preter- 
natural activity of the growing processes in the epiphysial line. Yolk- 
maan (Pitha und Billroth's Handbuch der Ghirurgie, Bd. ii. S. 350) is 
of the opinion that the elongation is due to irritation and increased blood- 
fiow, which extend to the epiphysial cartilages and set up in them in- 
creased cell-productiou. Paget {Surg. Path., vol. i. p. 82) says : — 

"The elongation of the bones in these cases may occur in different instances 
in two ways. In some cases it seems due to that change in bone .... 
which consists in the deposit of the products of inflammation in the interstices 
of tiie osseous tissue, their accumulation therein, and the remodelling of the 
bone around them as they accumulate. . . . But, in other cases, the elongation 
is probably due to the more genuine hypertrophy which follows the increased 
flow of blood." 

In regard to the treatment of this form of hypertrophy there is not 
much to be said. Drugs are powerless to check the progress of the dis- 
ease or to diminish the size of the enlarged bone. When, as in the present 
case, the affected structure constitutes an unsightly and inconvenient de- 
formity which can be removed, i^artial or complete amputation ought to 
be resorted to. When the disease occurs in one of the bones of the lower 
extremities, it is easy to mitigate the consequent difficulty in walking hj 
having one boot-sole made thicker than the other. In shortening of one 
of these bones after fracture, Rizzoli, an Italian surgeon, recommends 
breaking the corresponding bone of the other limb and allowing the 
fragments to overlap, so that shortening equal to that in the first-broken 
bone may take place.* It would certainly be quite as justifiable to break 
an elongated bone — and, by Rizzoli's method — to reduce it to its original 
length. Neither this nor any other surgical operation, if performed in 

1 Pitha u. Billroth, Bd. ii. Abt. ii. S. 249. 



118 



Wyeth, Occlusion of the Popliteal Artery. 



[Jan. 



adult life, is open to the objection that the disease may recur, since ex- 
perience has shown that the bones exhibit no tendency to undergo 
elongated hypertrophy after the developmental period is past. 



Cunal 



Art. XII. — Occlusion of the Popliteal Artery, vnth establishment of the 
Collateral Circulation. By Jno. A. Wyeth, M D., Assistant to the 
Chair of Anatomy at the Bellevue Hospital Medical College, New 
York. (With a wood-cut.) 

The subject from which this specimen was taken was a negro man, 
about thirty years of age. The occlusion was in the popliteal artery of 
the left leg. The case was found in the dissecting rooms of the Bellevue 
Hospital Medical College. 

A close examination of the condition of the vessel, while I was making 
the dissection, led me to infer that the primary occlusion was opposite the 

knee-joint, near the middle of the 
popliteal artery. The vein was more 
closely adherent here than at any 
other point, and the obliterated vessel 
was more fibrous here than either 
above or below. 

It is most probable that the acci- 
dent was the result of atheromatous 
and subsequent calcareous degenera- 
tion of the vessel, upon the roughened 
inner coat of which the thrombus 
gathered, that led to the complete 
occlusion. 

That the calcareous degeneration 
found in the specimen did not result 
from an embolus lodging here, and 
interfering with the nutrition of the 
vessel, is evident from the following 
facts : — 

1st. An embolus in all probability 
would not have lodged at this point, 
but would have been forced lower 
down and arrested at the bifurcation, 
into anterior and posterior tibial, only 
a few inches further, where there was 
a marked diminution in the caliber of 
the arteries. 




1876.] Wekr, Hysteria Simulating: Locomotor Ataxia. 119 

2d. The depeneratiou existed below the established and complete colla- 
teral circulation. 

3d. The vasa vasorum are not derived from the vessels to which they 
are distriljuted near their points of distribution. Hence the embolus could 
not account for the diseased condition the first few inches below the limit 
of obliteration. The collateral circulation in this instance was by two 
routes, neither of which followed the channel laid down by anatomists as 
the proper means of communication after ligation of this artery. 

The anastoraotica magna (given off within Hunter's canal) very much 
enlarged and tortuous in its course, divided, as is frequent with this vessel, 
into its deep and superficial branch. The deep branch was the one in- 
terested in this instance. 

Passing downward and to the inner side of the patella, instead of anas- 
tomosing with the internal articular branches of the popliteal and through 
these with the recurrent branch of the anterior tibial, the vessel became 
very superficial, turned downward, following the inner edge of the tibia, 
and at a point ten inches in a direct line from its origin, it inosculated 
with two muscular branches of the posterior tibial, the largest of which 
was derived two and a half inches above, and the other about five inches 
above the ankle-joint. 

The second route, much smaller than the first, was through a vessel derived 
from the femoral, i. e. (the superficial femoral) one inch above the upper 
end of Hunter's canal This branch passed downward and to the outer 
side of the popliteal space and anastomosed with a branch from the popli- 
teal artery which is usually distributed to the superficial structures of this 
region. The origin of this small and ordinarily insignificant branch limited 
the obliteration below, while the anastomotica magna was the upper limit. 
No injection matter could be discovered in any other vessels. All the 
articular branches of the popliteal were lost but one. There was no appre- 
ciable difference in the size of the two legs. No cicatrix or indications of 
previous ligation. 

The specimen is now the property of the Wood Museum of the Bellevue 
Hospital, a splendid collection, the gift of Prof. Jas. R. Wood, of New 
York City, to the profession. 

New Yokk City, Oct. 12, 1875. 



Art. XIII. — Case of Hysteria simulating Progressive Locomotor 
Ataxia. By W. H. Webb, M.D., of Philadelphia. 

The following case of hysteria is presented to the notice of the profes- 
sion for the purpose of showing how closely a serious organic disease of 
the spinal cord can be simulated by one of a functional chai'acter : — 



120 Webb, Hysteria Simulating Locomotor Ataxia. [Jan. 

Mrs. M., set. 35, married when 14^ years old ; menstruated for the first 
time two w-eeks after that event. Has had eight children and several 
miscarriages, the last of which was a produced abortion in March, 1873. 
Her constitution and general health have always been good. There was 
no hereditary tendency to disease, and her habits and mode of life have 
been somewhat luxurious. 

During the latter part of the summer of 1873, she received a severe 
mental shock, of a domestic character, which deprived her of sleep for 
several nights, and was the cause of constant worry and anxiety for a 
considerable period of time thereafter. She now became morose, did not 
care to see any of her friends, and avoided society, of which heretofore 
she had been passionately fond. This melancholic condition continued 
until about October 1, 1873, when she experienced sharp, shooting pains 
over all the body, particularly in the back and limbs, together with a sense 
of fulness in the throat and a constant desire to vomit ; she also had a 
feeling of constriction of the chest and abdomen. About the same time 
she noticed that her menses had ceased, which caused an increase of her 
sufferings, mental and physical ; she then had shooting pain in the womb, 
with a very peculiar, indescribable feeling in that organ. The pain now 
became so violent in character, over the whole body, that she could not 
control herself; she then went to bed and placed herself under treatment, 
though she got up at times, dressed herself, and took a walk. This con- 
tinued for about two months. About the middle of June, 1874, her arms 
became paralyzed, this additional trouble having been gradual in its pro- 
gress ; the severe shooting pain was now confined to the spinal column 
and lower limbs, continuing in severity for some months. At this time 
her sight became affected, black spots appearing before her constantly ; 
and she insisted upon her room being kept dark. 

I am indebted to her former physician for tlie following interesting notes 
of her case : — 

"There was about all the symptoms, which were periodically intensified, a 
strong hysterical manifestation. The treatment was by anodynes and anti- 
periodics. Only temporary relief was obtained, and then only when under the 
direct influence of anodynes ; the body of her uterus was somewhat sensitive 
to pressure, the os and cervix hypertrophied and ulcerated. The treatment of 
the uterine disease was in some degree satisfactory ; notwithstanding which, 
the symptoms of pelvic pains and intense burning, with sharp pains extending 
along the spinal column and down the leg.s and arms, returned again with in- 
creased severity. Nothing but anodynes had any influence in relieving the 
pains, and only then when in large doses often repeated, the relief being of a 
very few hours' duration. Without any material abatement of the symptoms, 
the arms became jerking and the fingers somewhat stiffened, witli loss of power 
in them. The lower extremities also lost power as well as sensation, besides 
which there was loss of control of the sphincter of the bladder. Although 
the urine did not flow continuously, it was voided unconsciously ; this latter 
condition lasting a number of days. The paralytic symptoms came on in June, 
1874. 8he remained in this condition until August, 1874, making little or no 
material improvement." 

When I saw the patient, October 17, 1874, she was in bed lying upon 
her back, a position which she had occupied, more or less, for about six 
mouths ; her arms were paralyzed, and with the utmost exertion on her 
part she could neither raise nor rotate them, nor move any of the fingers 
of either hand. She had full control of her lower limbs while in bed, 
moving them in any position that she desired, or in which she was directed 
to place them, but when taken out of bed and supported on both sides, it 



1876.] "Webb, Hysteria Simulating Locomotor Ataxia. 121 

was fo\iiul tliat it was witli cxtri'ine dilliculty that she could walk, she 
would throw her limbs in a quick and forcible manner, and her feet would 
be raised some distance from the floor, and if she was deprived of support 
she would fall down. This inability to walk or stand was due more to 
the want of co-ordination of the muscles than to weakness; "her feet 
would not come down in the place she intended they should." There was 
loss of sensation in the limbs. She was anaemic and much emaciated, but 
her countenance was not indicative of much snU'ering, thou<:^h she was 
constantly complainino; of severe pain. The skin was dry, and had lost 
its elasticity ; pulse 90, feeble and easily compressible ; respiration 22 ; 
tongue covered with a thick, dark, brownish coat; appetite very poor ; 
bowels constipated ; urine of the sp. gr. 1020, and contained albumen, 
corresponding in quantity to " 6. Feebly coagulahle,^^ according to the 
phraseology recommended by Dr. Christison to express the proportions 
observed by the eye ; temperature 100°. Her articulation was jjerfect, but 
her voice was considerably changed in character, and was what may be 
termed aphonic. Her mind had been clear during the whole time that she 
was a sufferer, and during all her illness she conducted, verbally, the affairs 
of her household, as well as giving instruction and advice to her husband 
in regard to his business matters. 

The pain in the spinal column was increased on pressure, this being the 
case especially when made along the cervical and lumbar regions, but, if 
her mind was diverted, and the same amount of pressure used, she would 
not give the same evidence of pain as she would when her mind was 
dwelling upon her trouble. There was some swelling over both wrists, 
and also over the joints of several of her fingers, the oedeoia at times being 
red, and extremely j)ainful on pressure, this not being the case in parts 
adjacent. 

Diagnosis. — Hysteria. But was there not a serious complication ? 
Did not progressive locomotor ataxia exist, for it has been stated that that 
disease has followed hysteria?' And surely here were the symptoms of 
Duchenne's disease : The full control of her lower limbs while recumbent, 
the characteristic walk, the inability to stand alone, the pain shooting 
down the limbs, the anaesthesia, the constriction of the chest and abdo- 
men, the imi)airment of vision, and the incontinence of urine. In order 
to settle this point a consultation was had with Prof. Da Costa, who, 
after obtaining the history of the case, applied the " Gaiffe battery" to the 
various groups of muscles of the right arm. No response was obtained, 
and but slight tingling sensation was experienced by the patient. When 
applied to the left arm, only a slight muscular contraction was observed, 
and there was more sensation experienced than in the right arm. Partly 
in consequence of these results, not uncommon ones in old standing cases 
of hysterical paralysis ; partly influenced by the general aspect of the case, 
Prof. Da Costa pronounced the disorder solely hysterical. 

Treatment.- — Tinct. ferri chloridi, 5ss; acid, muriatic. 5'j; aquae, q. s. ft. 
§iij. Teaspoonful three times daily, to be taken in water. She was 
ordered to be rubbed with a dry coarse towel over the whole body daily, 
and also to be taken out of bed and made to walk her room several times 
every day. This was continued for about one month, when slight improve- 
ment was noticed ; she was then ordered to take a carriage ride of two or 
three hours every other day, which was continued some six weeks, when 

' Flint's Practice of Medicine, tliird edition, p. 675, 18(J8. 



122 MuRSiCK, Excision of Coccygeal Bones for Coccygodynia. [Jan. 

the weather became so inclement that the out-door exercise was abandoned. 
Improvement continued, and on January 25, 18*75, there was evidence of 
the return of the menstrual function. This proof of the assurance that 
she would recover had quite a salutary effect upon the patient, for joviality 
soon took the place of moroseness. Feb. 13th, she had three convulsions, 
for the first time during her illness, and two on the following day ; they 
were of short duration, and but a few minutes' interval elapsed between the 
attacks. She had full control of her arms during the paroxysms, and her 
fingers, which were heretofore contracted, could be readily straightened out. 
February 18th, menses returned and lasted about twelve hours. March 
18th, menses returned and continued quite freely for two days. April 17th, 
menses returned and continued quite freely for three days, the patient suf- 
fering no pain, being quite cheerful, and gaining flesh. April 25th, has 
been suffering severe pain for the last two days in the abdomen, constrict- 
ing in character, with a return of the shooting pain in the lower limbs, 
the latter not so severe as in the earlier history of the case. Appetite 
good; bowels regular. Has not been taking the iron mixture regularly. 

June 21. Since the last notes of the case, the patient was obliged to 
visit Baltimore, Md,, and while there she had two convulsions of short 
duration. There has not been any menstruation since April 17th. During 
her absence she has suffered considerably from pain throughout the whole 
body, though not so severe as formerly. Her visit to Baltimore being of 
a business character, her mind was in constant agitation during the time 
of her absence from this city, which was about four weeks. June 28th, 
catamenia returned, and for two days the flow was quite free, and was 
more natural in every particular than at anytime since 1873. She is now 
free from pain ; appetite very good ; bowels regular ; sleeps well, and is 
gaining flesh rapidly. Her walk is now perfect in every respect ; she has 
full control of her arms, and as'much power in them as ever, but her fingers 
are slightly contracted, and there is very little power in them. The dorsal 
and palmar aspects of both hands are somewhat contorted, due, probably, 
to contraction of the aponeurosis. There was no menstruation in July, 
but from the 14th to the 18th of August the flow was quite abundant. 
She now, September 18th, considers herself well, and in as good a state of 
health as ever, save the cohdition of her hands as above stated. 
633 NoKTH IGth Street. 



Art. XIY. — Tioo Cases of Excision of the Coccygeal Bones for Coc- 
cygodynia. By Geo. A. Mursick, M.D., of Xyack, N. Y. 

The number of cases on record of ablation of the coccygeal bones for 
the cure of coccygodynia are few, though the disease is of comparatively 
frequent occurrence. I have had occasion to resort to it twice, in other- 
wise incurable cases, with the following results : — 

Case I Miss W., aged 29 years, a strong built, muscular woman, fell, 

in March, 1872, from a chair upon which she was standing, to the floor, 
striking lieavily upon her fundament. The contusion of the soft parts 
was quite severe, and the pain and soreness which followed confined her 
to the bed for several weeks, wiieu it partially subsided. Since then her 
health has failed her, and she has lost flesh and strength. 



1876.] MuKSiCK, Excision of Coccyi^eal Bones for Coccygodynia. 123 

Failing to get relief from Iier suffering, she finally came nnder my care 
in May, 1873, fourteen months sul)sequent to the injury. She then com- 
plained of severe jiains through the pelvis, but more ])articularly in the 
region of the rectum, which were always aggravated by walking, by rising 
from the sitting posture, during defecation, by pressure, and by any 
motion which brought the muscles of the parts into jilay. She also com- 
l)lained of dragging pains in l)0th ovarian regions, and of great irritability 
of the bladder. Upon examination per rectum I found great tenderness 
u|)on pressure against the coccyx, the two lower bones of which, were dis- 
placed and pulled forward towards the rectum. Upon examination yjer 
vaginam, I found the uterus acutely antefjexed — the fundus |)ressing upon 
the bladder and very sensitive to the touch. Menstruation was regular, 
but very painful, the pain extending through the whole of the pelvic 
orgiins. She informed me that previous to her fall she had never suffered 
pain during the menstrual period, nor from any uterine ailment. I am, 
therefore, inclined to believe that the flexion was produced by the fall — 
sudilenly — in the same manner that retroversion and retroflexion are pro- 
duced by like causes. The nature of the disease and the remedy for it 
were explained to the patient. Slie assented to an operation, and accord- 
ingly, on June 2, 1873, I proceeded to remove the two displaced bones. 
After anaesthesia by ether the patient was placed on her right side, the 
nates being brought close to the edge of the bed; the index linger of the 
left hand was introduced into the rectum, and the bones pressed well back, 
when, with a scalpel, an incision two inches in length was made in the 
median line down to the bone, and its attachments severed from it as far 
as possible. The left hand was then disengaged and the bones seized 
with a strong forceps, drawn outwards, their remaining attachments 
severed, and the bones removed without difficulty. 

Severe pains shooting through all the pelvic organs followed the opera- 
tion for several days, requiring the liberal use of opium. There was also 
retention of urine for three days, rendering the use of the catheter neces- 
sary. The wound was dressed with a weak solution of carbolic acid ; the 
discharge from it was very profuse for ten days, and nearly six weeks 
elapsed before it healed. 

Case II. — Miss S., aged about 25 years. Four years ago she missed 
her footing and slip|)ed down a flight of stairs, injured her coccyx, and 
severely contused the neighbouring soft parts. For two weeks she was 
confined to the bed. Since that time she has been more or less of an 
invalid by reason of pain located in the region of the rectum, and I'adiat- 
ing through the pelvis. The pain, as in the previous case, was increased 
by any act which caused pressure on, or motion in, the parts. She also 
suffered severely from dysmenorrhoea. Upon examination per rectum I 
found the parts in the vicinity of the coccyx very painful to the touch, the 
two lower bones were freely movable, but not displaced. The uterus was 
in its normal position — the fundus much congested and very sensitive. 

She, like Case I., had consulted several physicians without obtaining 
much relief, as the true nature of the disease had not been recognized. 

]\[ay 31, 1875. I removed the two lower bones of the coccyx as in the 
preceding case. 

The wound was dressed with lint soaked in solution of salycilic acid in 
oil. Severe pain followed the operation for more than two weeks. There 
was retention of urine for eight days, requiring the use of the catheter. 
The wound of operation did not heal until two months after. 



124 Sharpe, Chronic Albuminuria. [Jan 

Remarks. — The result of these operations was a cure of the coccygo- 
dynia, and relief from its disagreeable attendants. The subject of Case I., 
after appropriate treatment, entirely recovered from the uterine complica- 
tion, and is now in perfect health. Of Case II., the patient is still under 
treatment for her dysraenorrhoea, with what result remains to be seen. 

The operation is simple and easy of performance, Ijut the constitutional 
disturbance following it is out of all proportion to its magnitude — though 
as far as I am aware it is devoid of danger. The subsequent pain is very 
severe, and lasts for days. The wound is slow to heal, and the discharge 
is profuse and thin. This condition of things may depend upon general 
debility induced by disturbed nutrition following long-continued pain. 

Since the differentiation of this disease by Drs. Nott and Simpson, the 
coccygeal bones have been occasionally removed for the cure of it, and 
with successful results, especially in cases of traumatic origin. Five cases 
have come under my observation — two the result of falls, and three from 
difficult parturition ; of the latter class there was neither fracture nor dis- 
placement of the bones. Two of these were cured by palliative means 
after long-continued treatment. The third is still under observation. In 
the majority of cases the disease is of traumatic origin, and, when fracture 
or dislocation of the bones has occurred, the only remedy is excision. 
Subcutaneous section of the attachments of the coccyx may be sufficient 
in other cases, especially those of neurotic origin, where no palpable lesion 
exists, and of this class of cases many may be cured without resort to 
surgical procedure, though it is the most efficient method of treatment. 



Art. XV. — Five Cases of Chronic Albuminuria treated successfully 
idth large doses of Iodide of Potassium. By T. S. Sharpe, M.D., of 
Natchez, Missis.sippi. 

Case I. H. M , mechanic, ast. 80, was seen in summer of 1873. Was 

feeble and emaciated, appetite good, digestion unimpaired ; bowels consti- 
pated, face puffy, had been so for a month. Urine highly albuminous. 

He was treated with iodide of potassium, 10 grs. three times daily. At 
the end of seven days the dose was increased to 15 grs. and afterwards 
gradually until he took ^ drachm morning, noon, and night, when the 
puffiness of the face disappeared and tiie albumen gradually lessened in 
quantity and disappeared. He was dismissed in forty days 

Case II. In January, 1874, J. H , engineer, ajt 28, consulted me. 

His urine was albuminous, and contained epithelial casts and cells and some 
blood. He began the use of the potassium in 5 gr. doses, but was not bene- 
fited until he increased the quantity to 22 grs. The albumen, cells and casts 
then gradually disappeared. To arrest the escape of blood corpuscles I 
gave him 10 gr. doses of gallic acid. He was dismissed in thirty-two days. 
At one stage of the disease this patient urinated 17 times in 24 hours. 

Case III. S. B , planter, ait. 65, consulted me for " general debility, 



1870.] Lkntk, Case of Lal)oar witliout Liquor Aiiiiiii. 125 

slow fever, and dropsy'' in Feb. 1 8T4. I found a very larjj^e quantity of alliu- 
men in liis urine. He passed only a small (juaiitity of urine at a time, l)ut as 
often as every two hours night and day. Under the iodideofi)otassium treat- 
ment and a terrufrinous tonic he was restored to health in forty-four days. 

Case IV. E. 13 , negro, xi. 58, came " to be cured of bloody water 

and a stricture." Was much emaciated; had been under treatment for five 
months. Urinated every two hours, and the violent straining which accom- 
panied each act forced feces from his bowel. The urine not only contained 
blood, but albumen in considerable quantity. Dilatation of the urethral 
stricture gave him great relief. He soon passed urine without an effort, 
which enal^led the sphincter to control the rectum. Iodide of potassium 
was given in increasing doses until he took 32 grs. morning, noon, and 
night. On tlie thirty-fourth day from the initial visit all traces of albumen 
had disai)peared. Gallic acid arrested the escape of blood. 

Case V. A young woman, ;ct. 22, dyspeptic and dropsical. Her urine 
was albuminous, and contained epithelial casts and cells. Until relieved 
of dyspepsia her stomach could not tolerate the potassium. On the 12th 
day, however, a tolerance was established, and tlie salt was administered, 
and the quantity cautiously increased until she took 36 grs. daily, when 
the symptoms of chronic albuminuria disappeared. 

Bemarka. — In none of these cases did the iodide produce the peculiar 
unpleasant results attributed to large doses of the remedy, but it invaria- 
bly increased the api)ctite and the flow of urine. 

I questioned each patient as to the probabilities of a syphilitic taint 
being present : every one protested against the suspicion. 

My friend, Dr. Jno. C. Inge, of this place, has treated, within the past 
two years, four cases of this disease with large doses of the iodide of 
potassium, with similar results. 



Art. XVI. — Case of Labour loithout Liquor Amnii. By Frederick 
D. Lente, M.D., formerly of Cold Spring, N. Y. 

Mrs. , the widow of a distinguished physician of New York City, 

and the mother of five children, was, by her own calculation, always 
previously correct, by mine, and by that of her husband, who died not 
long before her confinement, at the end of the tenth month of her preg- 
nancy, when she was taken with labour-pains March 19, 1871. Was first 
seen by me at 4 A. M., two hours after. Os completely dilated ; head pre- 
senting left occipito-anterior. Asked the nurse, a very competent and ob- 
servant woman, when the membranes had ruptured ; was told by her, and 
assured by the patient, who was perfectly cool and collected, that the 
napkin had not been moistened by any discharge. No liuid could be 
detected by palpation over the uterine tumour. Foetal heart beating 
loudly in left iliac fossa. Dr. Fordyce Barker, who had been summoned 
at the same time with myself, came in soon after my arrival. The pains, 
though severe, were not expulsive. Chloroform was administered, but 
no progress was made. The abdominal muscles were flaccid and did not 
contract at all. The plan of compressing the uterus firmly ivith both 
hands during the pains was therefore resorted to, and with complete sue- 



126 Lente, Case of Labour without Liquor Amnii. [Jan. 

cess ; two pains, thus assisted, delivered the head, and the body followed 
slight traction. The uterus contracted well. Not a drop of fluid, oilier 
than a very little blood, accompanied or foUoioed the delivery. The 
placenta came away spontaneously. The child scarcely breathed, and 
was almost as pale as if it had died from hemorrhage. Assiduous atten- 
tion, on my part, by friction, slapping, application alternately of heat and 
cold, brandy externally and internally, and some artificial respiration, 
was necessary, for nearly an hour, before regular respiration was estab- 
lished. The child was still so white and feeble that stimulants were 
directed at short intervals. It rallied after a time, and some hopes were 
entertained of its ultimate recovery, but it gradually sank and died after 
two or three quasi convulsions of a mild character. 

Until the occurrence of this case, I had not met with a similar one; 
cases of "dry labour" being quite different ; in these, the waters having 
escaped by premature rupture of the membranes, or in consequence of 
the protracted character of the labour. There are some points which are 
worthy of comment. The "motion" of the foetus was quite strong until 
March 1st, when it gradually declined until the thirteenth, and then 
ceased. But the pulsation of the heart was quite distinct. The uterus 
bad the firm, solid feel of a fibrous tumour. It seems probable that on 
March 1st the secretion of liquor amnii ceased, and that the supply 
already existing was gradually exhausted ; then the compression of the 
child prevented active movement, and this compression, increasing with 
the approach, and the actual commencement and progress, of labour, 
and thus interfering, for a protracted period, with the peripheral circu- 
lation, caused the marked bloodless appearance of the surface, and the 
depression of vital power, which led to the death of the infant in spite of 
the full establishment of respiration. 

I was led to publish this case, after the lapse of four years, in conse- 
quence of seeing the report of a similar one, by Dr. F. A. Burrall, in the 
Oct. No. of this Journal, and of some practical remarks by him which de- 
serve attention. 

On examining his patient, the doctor found, as he says, the membranes 
intact. Returning some time after, he was disappointed in finding no 
progress, and the membranes still entire. He endeavoured to rupture 
the supposed membrane with the sharp nail of his finger ; and was actu- 
ally about to use some sharp instrument, when he thought he felt some- 
thing like the fine hairs of the scalp. He delivered with forceps. " No 
membranes were visible during the operation." It is important for obste- 
tricians, therefore, to bear in mind that such cases, though very rare, may 
again occur, and that so competent and observant a practitioner as Dr. 
Burrall could not accurately distinguish the caput auccedaneum from the 
"bag of waters." .... "At such a time," he says, "the perception of 
the fine hairs upon the scalp of the child would be a diagnostic mark be- 
tween them." 

P.\LATKA, Florida. 



1876.] 127 



(Article XVII.) 

A CETsTUllY OF AMERICAN MEDICINE. 

1TT6-1876. 



I. 

PRACTICAL MEDICINE, 

By Edward H. Clarke, M.D., A.A.S., late Professor of Materia Medica in 
Harvard University.' 

AND 

A HISTORY OF THE DISCOVERY OF MODERN 
ANAESTHESIA, 

By Henry J. Bigelow, M.D., t'rofessor of Surgery in Harvard University. 



PRACTICAL MEDICINE. 

When Boerhaave, the most accomplished and celebrated physician of 
the 18th century, died, he left behind him an elegant volume, the title- 
page of which declared tliat it contained all the secrets of medicine. On 
opening the volume every page, except one, was blank. On that one was 
written, " keep the head cool, the feet warm, and the bowels open." This 
legacy of Boerhaave to suffering humanity typified, not inaptly or un- 
justly, the acquirements, not of medical science, but of medical art at the 
close of the l^th century. Empiricism, authority, and theory ruled the 
medical practice of the world at that time. The result of therapeutical 
experience from Hippocrates to Boerhaave was fairly summed up by the 
latter in the eleven words we have just quoted. To quiet the nervous 
system, to equalize the circulation, to provide for the normal action of 
the intestinal canal, and to leave all the rent to thfi vis viedicalrix naturse 
was sound medical treatment, and it was as far as a sound therapeutics 
had gone a hundred years ago. This goal had been reached by empiri- 
cism. Wise practitioners like Boerhaave, Sydenham, Morgagni, and a 
few others, were content to restrain their materia medica within these 
modest limits. The vast majority of practitioners, however, either blindly 
followed the authority of the past, and bled and dosed by the book, or 
adopted some strange theory of planetary influence, signatures, animal 
spirits, or occult force, and treated disease in accordance with whatever 
theory they chanced to believe in. Medical practice, as a rule, deserved 
the ridicule of Moliere and the satire of Montaigne 

In making these statements we do not forget that there had been real 
progress in many departments of medical science. Anatomy, physiology, 
surgery, chemistry, and physics had made substantial conquests within 
their own domains. We do not forget that Harvey had discovered the 
circulation of the blood ; that Haller, one of the greatest names in me- 
dicine, had discerned the fact of muscular irritability, and its connection 

' The author desires to acknowledge his indebtedness to Dr. R. H. Fitz, 
Assistant Professor of Pathological Anatomy in Harvard University, for invaluable 
aid in collecting many of the data upon which this essay is founded. 



128 A Century of American Medicine. [Jan. 

with the nerves ; that Albinus had introduced thoroughness and exactness, 
so far as the means and instruments of observation accessible to him 
rendered them possible, into anatomical investigation ; that Morgagni 
had founded the science of pathological anatomy, which has since yielded 
such magnificent results; that Astruc in 1743 had announced the reflex 
phenomena of the nervous system, which Prochaska before the close of 
the century more fully developed ; that Boerhaave, Sydenham, Mead, 
Hoffmann, and Stahl had rendered good service to practical medicine ; 
that Franklin and others had brought electricity, magnetism, and galvan- 
ism into the domains of science, though their relations to medicine and 
physiology were not then recognized ; and that chemistry had entered 
upon a career of investigation which it has since followed with extraor- 
dinary success. But all these discoveries were in the nature of isolated 
facts. They were more like islands, surrounded by an unknown ocean, 
than like parts of a continent, intimately connected with each other and 
forming portions of a grand and systematic whole. 

In spite of these achievements, however, theory, empiricism, and au- 
thority ruled the medical world at the close of the 18th and beginning of 
the 19th century. Let us look at some illustrations of this statement. 

Cullen, who flourished during the middle of that century, reasoning 
from a priori considerations, founded his pathology and nosology upon 
pure theory. He not only did this, but he recognized the fact that he 
did so and defended himself in doing it. He declared it to be the duty 
of a philosophical inquirer in medicine to control his observations by his 
theories, and not his theories by his observations. In like manner he 
maintained that the medical practitioner should be guided at the bedside, 
less by the indications of nature than by theoretical considerations. Such 
was the attitude with regard to the theory and practice of medicine of 
one of the most philosophical thinkers and learned physicians of that 
period. He was by far the ablest of the solidists. His views met with 
general acceptance in England, and excited a great influence upon the 
medical opinions and practice of this country, and especially of New Eng- 
land. Much of the practice of our fathers and many of their medical 
opinions may be traced directly to Cullen. He was too often obeyed as 
a superior. Fortunate was it that the common sense and independence 
of American physicians often led them to refuse obedience to his autho- 
rity and to follow the guidance of rational empiricism. 

Brown's theory of medicine, which appeared not long after that of 
Cullen, is another illustration of the speculative tendency of medicine at 
that time. Brown was a man of less breadth, learning, and power, but of 
a more practical turn, than Cullen. His practical tendencies led him to 
base his system chiefly on therapeutics. Its pathology was essentially 
that of Cullen, and its physiology a misconception of the Hallerian notion 
of irritability. It^- essential error was that it rested not upon facts, but 
upon assumptions. Its motive was a desire to substitute a stimulating for 
a lowering method of treatment. Its practical characteristics, however, 
caused it to spread more rapidly and to exert a more profound influence 
over the medical opinions and practice of his time than tliat of his more 
philosophical contemporary. It rapidly made its way into Germany, 
France, and Italy. Dr. Rush, of Philadelphia, illustrious as a practitioner, 
writer, and signer of the Declaration of Independence, who was a disciple 
of Brown, imported it into America, Introduced under such auspices, 
it spread rapidly throughout the country and produced a deep and lasting 
impression upon American medicine. 



187fi.] Practical Medicine. 129 

The speculative tendency to which we have referred, found its most 
extravauaiii expression and attained its largest development in the theory 
which Hahnemann framed near the becrinniiif"; of the present century. 
A]tlionc:h, on account of its manifest absurdities, it was rejected by all 
scientific men, yet, to the philosophic student of the history of medicine 
for the past hundred years, it is interesting?, not only as a curious instance 
of the afterration of the human intellect, but because, without contribut- 
ing at all to the progress of medical science, it has modified the thera- 
peutics of the present asre by reminding the physician of the limits of his 
art, and of the great i)art which nature plays in the cure of disease. 
Hahnemann ignored ail [)revious medical knowledge. He denied that 
medicine was a l)ranch of natural science; that any knowledge of anatomy, 
or physiology, or pathological anatomy, or of diagnosis, or of the inves- 
tigation of the nature of disease was necessary to the physician ; and also 
denied the existence of any curative power in the human system. Con- 
sciously, or unconsciously, abstracting from the mediaival doctrine of sig- 
natures its guiding principle, that the like colour cures the like colour, 
he declared that like cures like, similia similibus curantur. To this he 
added the doctrine of the potency of dilutions, and later admitted certain 
diseases which he called psora, sycosis, etc., as modifying elements. 
Symptoms and groups of symptoms were all that were worthy of the 
attention of the physician, and these were to be treated by potencies in 
accordance with his fundamental theory. It is unnecessary to allude to 
the modifications which this theory has undergone at tlie hands of his 
disciples. It is sufficient for our purpose to recogrfize it as a sort of 
zymotic element in the progress of medical art in this country and Europe, 
and one which, notwithstanding its activity for a considerable period, is 
now declining. 

Such was the condition of medical science and art at the close of the 
eighteenth century. A few great minds isolated from each other, slaves 
to no theory, emancipated from authority and dissatisfied with the results 
of empiricism, busied themselves with the accumulation of facts whose 
value they scarcely recognized, but which the future would gladly use. 
Others, and a larger number, were framers, or disciples, or advocates of 
some sort of theory, whose foundations were almost purely hypothetical. 
The vast majority of practitioners, slaves of a routine which authority 
had sanctioned, were guided solely by empiricism. The outlook was by 
no means cheerful. It was evident that if medical science was to ad- 
vance, and a rational therapeutics ever to l^ecome possible, some new 
element, or force, must be introduced. Fortunately this new element, or 
force appeared. It was introduced by two men, John Hunter of Eng- 
land, and Bichat of France, who may be justly called the founders of 
modern physiology and pathology. 

John Hunter was one of those remarkable men who only appear at 
rare intervals, and who, if they enter the arena of politics, mould the 
fate of an empire; if that of theology, change the faith of the age; 
if that of science, enlarge the boundaries, and add to the sum of human/ 
knowledge. He recognized that medicine was one of the natural sci- 
ences, more or less intimately connected with all of them, and to be studied 
as they are by rigid and careful observation. Theory was useless, except 
so far as it rested upon facts. He regarded a knowledge of the whole 
organic and inorganic world as necessary to a just comprehension of the 
structure a*id functions of man. " He determined to contemplate nature 
No. CXLL— Jan. 1876. 9 



130 A Century of American Medicine. [Jan. 

us a vast and united whole, exhibiting, indeed, at different times different 
appearances, but preserving, amidst every change, a principle of uniform 
and uninterrupted order, admitting of no deviation, undergoing no dis- 
turbance, and presenting no real irregularity, albeit to the common eye, 
irregularities abound on every side.'" With such an object before him, 
he proceeded to collect data of every kind. The Ilunterian Museum in 
London testifies to his indefatigable industry, and to the extent and 
accuracy of his researches. His method of investigation and of reasoning 
has served as a model for the age that followed him. His influence upon 
American medicine was not less potent than upon that of England and 
the rest of Europe. 

At the time Hunter was at work in London, his great contemporary, 
Bichat, was engaged in those researches in France which have rendered 
such inestimable services to physiology. Bichat died young, but he lived 
long enough to show that he was one of the world's greatest minds. 
"Between Aristotle and Bichat," says Bm-kle, "1 can find no middle 
man." He and Hunter represent the turning-point in medicine from 
idealism, speculation, and theory, to accurate and close observation. 
His great merit lay in recognizing the fact that power depends on struc- 
ture, and the additional fact that a knowledge of structures can only be 
obtained by studying the formation of the tissues that compose them. 
By following the method of Bichat, Agnssiz was led to the remarkable 
discovery of the intimate connection*of the tegumentary membrane of 
fishes with their whole organization ; by the same method, Cuvier, Owen 
and others ascertained the intimate relation of the teeth of an animal to 
its whole organization. The great discoveries in physiology of the past 
hundred years, are due to the fidelity with which physiologists have sub- 
stantially followed the line of investigation marked out by Bichat and 
Hunter. 

The American Revolution, which was the forerunner of political 
changes of the gravest character in Europe as well as in America, was 
coincident with this new departure in medicine. American medical sci- 
ence was necessarily an offshoot from that of Europe. While it inherited 
the traditions, the superstitions, the theories, the authority, and the em- 
pirical results of Europe, it also gratefully welcomed the independent 
thought and sound method of Hunter and Bichat. William Hunter's 
magnificent work on the gravid uterus (which for accuracy and com- 
pleteness has never yet been surpassed) appeared in 1774. It v.as an 
admirable example of the results of careful investigation, and was a most 
auspicious illustration of what the new century was to accomplish. From 
that time to this the progress of medicine in all its branches has been of 
the most gratifying character. Although it is true, as Tennyson says, 
that 
"Science moves Init slowly, s'.owly creeping, creeping ou from point to point, ''^ 

yet, as we look Ijack upon the past hundred years, we find that its march 
has been one of extraordinary rapidity. During this period, more of 
nature's great resources have been discovered, and more of her secrets 
found out than ever before. A thousand doubtful suggestions have 
ripened into facts. The telegray)h, the locomotive, the steamship, the 
photograph, the spectroscope, and other discoveries more than we can 

• Buckle's History of Civilization in England, vol. ii. p. 44(5, Am. ed. 
s Locksley Hall. 



1876.] Practical Medicine. 131 

enumerate, testify to the century's scientitic activity. In politics this 
century has witnessed " tlie sei)aration of America from Great Britain, 
the formation of the United States, the nieetino: of the Tiers-Etats, the 
revolution, tiie downfall of the French monarchy, the repul)lic, the rise 
of Napoleon, the mijility European wars which altered the face of Europe 
and ended with the ' Hundred Days' and the exile of the Corsican tyrant, 
the restoration of the Bourbons and their ruin, the Monarchy of July, 
the Second Republic, the Second Empire, the Third Republic, the Com- 
mune, and the humiliation of France by a power which but the day before 
had been a mere federation of incoherent atoms, the Septennate, the 
unitication of Germany and of Italy."' In theology all faiths, from that 
of Catholic Rome to that of the latest Protestant sect, have been at- 
tacked, and they themselves have given unmistakable signs of hesitancy 
and change The faith of Christendom has been, and is, crystallizing 
into new forms, and moving to new issues. It is not an extravagant 
assertion to say that in all this turmoil, change, and progress, medicine 
has kept abreast of the other natural sciences, of politics, and of theology, 
and has made equal conquests over authority, error, and tradition. 

If this statement seems extravagant, it is to be recollected that the 
brilliant discoveries in natural sciences and the arts, the great political 
changes, and the vacillations of long-established faiths to which we have 
referred, influence so obviously the fate of nations and the aspects of 
civilization, that they force themselves prominently upon our attention, 
while the progress of medicine is silent and unobserved. Yet the pro- 
gress and changes of the latter are not less real than those of the former, 
and, perhaps, affect more profoundly than they, the development of 
civilization and the welfare of the human race. 

During the past century, medicine has been enfranchised from super- 
stition, quasi-cliarlatanism, bald empiricism, and speculation, and has 
developed into a symmetrical science, affiliated with the other natural 
sciences, studied by the same methods and the same appliances as they 
are, and, like them, has been planted upon the solid basis of fact and 
demonstration ; pathological anatomy, starting from the de Sedibus of 
Morgagni and the labours of Baillie, and illustrated by the later re- 
searches of Rokitansky, Cruveilhier, Virchow, Recklinghausen, Cohnheim., 
and others, has become a fundamental branch of medical science ; obstet- 
rics, rescued from the hands of ignorant midwives, has been raised with 
its allied branch, gynaecology, to its legitimate position as a science; 
preventive medicine and hygiene, cultivated to an extent previously 
unknown, have prolonged the average of human life : organic and phy- 
siological chemistry have been substantially created, and achieved 
important and brilliant results ; physiology, guided by Biumenbach, 
Magendie, Legallois, Dumas, Flourens, Johannes Miiller, Carpenter, 
Schiff, Helmholtz, Claude Bernard, Hammond, Dalton, Flint, Weir 
Mitchell, and others, has grappled with the abstrusest problems uf struc- 
ture and life, and has revealed so much as to make timid people tremble 
at the audacity of its efforts; the reflex action of the nervous system, 
first discovered by Astrnc and Prochaska, has been shown by the admi- 
rable investigations of Sir Charles Bell, Magendie, Marshall Hall, Claude 
Bernard, Brown-Sequard, and their associates, to be, next to the dis- 
covery of the circulation of the blood, the most important addition to 
physiological knowledge that has yet been made — one that has illustrated 

' Tlie Nation, August 19, 1875. 



132 A Ckntury of American Medicine. [Jan. 

and explained the complex and almost inexplicable nature of the nervoiif? 
system ; the inhibitory and vaso-motor system of nerves has, in part, 
been discovered ; the velocity with which sensation, thought, and volition 
are transmitted along the nerves has been measured and determined; 
the automatic action of the nervous system, and the position of the 
ganglia as centres of nervous power, have been demonstrated ; the secrets 
of digestion and assimilation have been disclosed ; by a method of explora- 
tion, which Auenbrugger and Laennec discovered, and Louis improved, and 
Skoda has shown to be in harmony with the laws of acoustics, the interior 
of the chest has been laid open to examination, so that the condition of the 
lungs and heart can be marked out with an accuracy like that with which 
the engineer maps out the topography of a mountain ; the natural history 
of some of the gravest diseases has been ascertained, and means of pre- 
venting or curtailing them discovered ; the ophthalmoscope has revolu- 
tionized ophthalmology ; the microscope has penetrated the secrets of 
structure and tissue ; the spectroscope has traced the devious wandering 
of drugs from the stomach to the remotest organs of the body ; the 
sphygmograph has revealed the unseen and delicate movements of the 
heart and pulse ; the sesthesiometer has measured the sensitive power of 
tissue and nerve ; the dynamometer has recorded the force of the muscles; 
chemical analysis has traced the transformation of food into various forms 
of force, such as motion, heat, and thought ; the materia medica has been 
made rational and effective by cleansing it from the disgusting animal 
excreta and filthy compounds that defiled it, from the absurd farragos 
and useless formulas that superstition or theory had foisted into it, and 
by adding to it numerous agents that botany and chemistry have dis- 
covered; last of all, and most important of all, the grandest discovery 
of the ages, that which will render this century remarkable for all time, a 
class of anaesthetic agents has been discovered by which surgery and 
death even are deprived of half their terrors, and the physician at his 
will enabled to compel pain to disappenr and distress to be quiet. 

Such has been the progress, and such are some of the achievements 
of medical science for the past century. They are enough to justify the 
enthusiastic regard in which physicians hold their profession, and enough 
to deserve, as they have received, the gratitude of mankind. After this 
survey of the general progress of medicine for the past hundred years, 
we are prepared to estimate more correctly than would otherwise be 
possible, the part which the United States has taken in aid of this pro- 
gress and in attaining these results. 

In making up our estimate, however, let us remember that a large 
amount of scientific work cannot justly be expected of the medical pro- 
fession in a new country. When the nation hud acquired its independence, 
its population extended along a narrow coast-line from what was then 
known as Massachusetts, now Maine, to Georgia. The inhabitants had 
the Atlantic Ocean in front of them, and in their rear the unexplored 
forests, tilled with aborigines, that stretched far away towards the I'ncific. 
As a matter of necessity they were obliged to occupy themselves almost 
exclusively with the task of obtaining a secure existence in a new 
country. For the first fifty years of the nation's life, the necessities of 
the present left little leisure for the cultivation of the arts and sciences. 
The medical profession were compelled by their position to devote them- 
selves almost, if not quite exclusively to the practice of their profession, 
and to leave scientific investigation and discovery to a later period. 



1870.] Practical Medicine. 133 

There was no siippral»iindaiice of educated physicians. If Boerhaave, 
Culieii, Hunter, or Bichat had found themselves in America at that time, 
they would have been obliged to take care of the sick, rather than inves- 
tigate the laws of disease and of life, and the world wonld not have 
heard of them as original investi<rators and natural philosophers. 

Over fifty years ago, Sydney Smith, alluding to the slow progress of 
intellectual development in the first half of our national e.xistence, said in 
the Edinbiirtjh Revieio : — 

'•The Americans are a brave, industrious, and acute people, hut thoy have 
hitherto made no approaches to the heroic, either in their morality or their 
character. During the thirty or forty years of their in(l('i)endpuce they have 
done absolutely uothinu' for the sciences, for the arts, for literature, or even for 
the statesmanlike studies of politics and political economy. . . . In the 
four quarters of the globe, who reads an American book ? or goes to an Ame- 
rican play? or looks upon an American picture or statue ? AVhat does the 
world yet owe to American jjhysiciaus or surgeons? What new substances 
have their chemists discovered, or what old ones have they analyzed? What 
new constellations have been discovered by the telescopes of Americans? 
What have they done in mathematics? Who drinks out of American glasses, 
or eats out of American plates, or wears American coats or gowns, or sleeps 
in American blankets?" 

It must be confessed there was a great deal of truth in his statements 
at that time. Naturally enough his words rubbed the backs of all loyal 
Americans the wrong way, and everybody cried out accordingly. At 
the present time we can read his biting language with equanimity. If 
the first half century of our national existence did not yield much to 
science and art, it produced all that eonld have been justly expected of 
it; and the last half has produced books, manufactures, discoveries in 
the arts and sciences of every kind that have gone over the four quarters 
of the globe. We can now fairly ask. Who does not read an American 
book? and can point with honest pride to the services which American 
physicians and surgeons have rendered to the world. 

When Sir Humphry Davy was asked what he considered to be his 
greatest discovery, he replied, Faraday. In like manner we can justly 
say that American physicians and surgeons are the best contribution of 
the United States to medical science and art. The work which the phy- 
sicians of the first age of the republic performed, and the way in which 
they performed it, proved them to be men of whom the nation need not 
be ashamed. Men like Rush, Physick, and Chapman, of Philadelphia, 
Hosack, Watson, Francis, and Mott, of New York, the Jacksons, War- 
rens, and Bigelows, of Boston, Dudley, of Kentucky, and many others 
whom our space does not permit us to name, are contributions to science 
of the best sort. To the example and stimulus of their lives and work, 
may be justly ascribed, to a very considerable degree, the honourable 
position, acknowledged zeal, practical judgment, and sound attainments 
of the American medical profession of the present day. We have already 
referred to the intimate connection that existed a hundred years ago, and 
that fortunately still exists, between the medical science of Europe and of 
this country. The latter is not different from the former. The two are 
parts of a common whole. Even the war of the revolution scarcely dis- 
turbed this connection. An illustration of it is to be found in the fact 
that in the same year, 1796, in which Jenner vaccinated his first patient, 
Dr. Waterhouse repeated the operation in Cambridge, Massachusetts, and 
Dr, James Jackson in the neigbouring city, Boston. Another illustration 



134 A Century of American Medicine. [Jan. 

of tlie same thing; is shown in the education of American physicians. 
From the era of the revolution until now a larjre and constantly increas- 
ing number of American physicians, after having completed the curricu- 
lum of medical study in this country, have resorted to European schools 
for the completion of their professional preparation. Dr. Samuel Bell- 
inghani, who graduated at the first commencement of Harvard College 
in 1642, afterwards ol^tained the Doctor's degree at Leyden.^ The best 
American education has always consisted in getting the best medical in- 
struction that Europe and Ameiica jointly impart. Our medical schools 
are an honourable contribution to the medical work of the century. 

We learn from Dr. Carson's History of the University of Pennsylvania, 
that the first course of medical lectures given in Philadelphia (and pro- 
bably in this country) was delivered by Dr. Cadwalader, prior to 1751. 
The first systematic courses of lectures on medical subjects were given in 
Philadelphia a little more than one hundred years ago by Drs. Morgan 
and William Shippen, who were the fathers of medical teaching in Ame- 
rica. The degree of Bachelor of Medicine was first conferred in Phila- 
delphia in 1768, and that of Doctor of Medicine in New York in 1770. 
From these small beginnings sprang the medical colleges, which have 
ripened into the large institutions of Philadelphia, New York, and Bos- 
ton, and into numerous other medical schools, too many we fear for the 
good of the profession and of the country, that are to be found in most 
of the cities, and connectedwith many of the colleges of the Union. 

These medical schools were* not founded by the State, nor are they 
controlled or supported by it. A few and only a few of them have been 
scantily endowed by ]»rivate individuals. Their support depends upon 
the fees derived from the students that resort to them. They were called 
into existence by the necessities of the times when they were established, 
and from one decade to another have been modified in their organization 
and methods of instruction so as to meet the demands made upon them. 
They are the natural and necessary growth of circumstances. It would 
be an interesting and easy matter to trace them from the small beginnings 
that we have indicated to their present proportions, and to point out the 
law that has governed their development ; bnt our limits permit only the 
briefest possible exposition of it. 

During the colonial period, and for some time after the establishment 
of the republic, medical students derived their professional training, not 
from schools or universities, but from practitioners of greater or less emi- 
nence, with whom, to use a technical |)hrase, they entered their names as 
apprentices or students. By this arrangement they had the use of the 
library of their master, whose shelves, if not abundantly su|)plied, generally 
held a few books, and whose house usually contained in some closet or 
nook a few bones of the human frame, or perhaps an entire skeleton. 
These the student handled, e.xamined, and studied. His opportunities for 
clinical study consisted in witnessing, and often assisting in the office prac- 
tice of his master. There he pulled his first tooth, opened his first abscess, 
performed his first venesection, applied his first blister, administered his 
first emetic, and there first learned the various manipulations of minor sur- 
ger}' and medicine. After a time his clinical op})ortunities were enlarged 
by visitiiig with his teacher the patients of the latter, and becoming acquaint- 
ed, not in hospitals but in private houses, with the protean phases of dis- 

' Historical Address. Dr. J. B. Beck, New York. 



1876.] Practical Medicine. 135 

ease. His clinical lectures were his master's talk on the cases they had 
visited ns they rode from honse to house. After three years spent in tiiis 
sort of study and practice, the younp^ man was supposed to have acquired 
enough medical knowledge to enable him to commence the practice of 
his profession. In proportion as a jihysician or surgeon became eminent, 
students who had the means to do so Hocked to him, and he became the 
centre of a medical school. His clinical instructions, instead of being 
the talks that beguiled the way of a long ride, were changed into formal 
lectures delivered in his study or in some private room. Those who 
proved to be tlie most popular teachers, and who lived in the same city 
or neighl)ourhood, associated tiiemselves together for purposes of teacii- 
ing. Thus were founded the medical schools of Philadelphia and other 
cities. They did not give, and were not intended to give, a complete 
medical education, but only to supplement the instruction of private 
teachers. The courses of lectures were few in number and brief in ex- 
tent. Students still continued to enter their names, and study for the 
major part of the year with some medical man in their own neighbour- 
hood, and to attend lectures, as it was called, otdy three or four months of 
the year. Gradually a larger demand was made upon the schools ; their 
lecture terms were lengthened; professorships were subdivided; new 
ones were added ; hospitals were utilized for clinical instruction ; the 
schools continued to enlarge their curricula of study, and at length added 
summer instruction to their winter's work; museums were established; 
chemical laboratories were formed ; microscopical departments created ; 
and all the appliances were attached to schools that are necessary in the 
investigation of structure, life, and disease. This process of growth has 
not yet stopped. It is still going vigorously on. One university. Har- 
vard, requires all its medical students to go through a systematic course 
of training, under its ov.'n supervision, by a corps of teachers of its own 
appointment. 

It is evident, from this brief sketch of the medical schools of the United 
States, that they are different in their organization, and to a considerable 
extent in their objects, from those of Europe. It is equally evident that 
the former are gradually approximating the latter, though it is not likely 
that their organization, methods of instruction, and character will ever 
be the same. The fact that the European schools are founded and con- 
trolled by the State, and are to a large extent responsible to it, and that 
American schools are independent institutions, self-supporting, and respon- 
sible only to ijublic opinion, necessarily impresses a distinctive character 
upon the medical schools of the two continents. The atmosphere of each 
is different ; each leads a different life ; and each will produce a different 
result. Admitting such to be the case, it does not follow that the medi- 
cal schools of the United States are necessarily of an inferior character, 
or that the physicians who graduate from them are imperfectly educated. 
For the schools, except in the case of Harvard, just referred to, do not 
pretend to give a complete education, but oidy to supplement that which 
the student gets elsewhere. Indeed it may be affirmed that those who, 
like the apothecary of England and the Secundiir Arzt of Germany, are 
charged with the medical care of the mass of the community in Europe, 
are not better equipped for the practical work of their profession than 
their average American contemporary. We do not mean to assert by 
this that the scientific training of our schools is equal to that of 
Vienna, Berlin, or Paris. But we do assert that if the necessities 



136 A Century of American Medicine. [Jan. 

and different conditions of Europe and America are impartially com- 
pared, we shall find tliat the American method of medical education 
yields as ^ood a practical result to the nation as the European method 
of medical education does to Europe. And we further assert that 
the flexibility of the American method permits of chantre, growth, and 
development, in correspondence with the demands of each succeeding age, 
more easily and more rapidly than is possible with the conservative 
organizations of Europe. Hence we are not ashamed to present our 
medical schools, with all their short-comings and imperfections, as sub- 
stantial contributions to the practical medicine of the century. And, 
moreover, we can justly point to graduates of these schools, some of 
whom have, and others of whom have not, been fortunate enough to add 
to their American a European education, as in every way the peers of 
European physicians or surgeons. 

It was a noteworthy and fortunate circumstance, that at the time of 
the establishment of the republic, the medical profession of the new 
nation contained a large number of intelligent, able, and well-educated 
physicians. Pre-eminent among these was Dr. Benjamin Rush, of Phila- 
delphia, who devoted himself with enthusiasm to his profession, which he 
studied first in Philadelphia, and afterwards in Edinburgh. An ardent 
patriot, a lover of liberty, a friend of Washington, a signer of the Decla- 
ration of Independence, he was not only eminent as a physician, but dis- 
tinguished as a philosopher and a scholar. Holding a high social posi- 
tion in a community, noted alike for its love of the arts and sciences, and 
for the graces of social life, he contributed largely to raise the profession 
of medicine in the estimation of the community in which he lived, aud of the 
whole country. During the Revolutionary war he rendered essential service 
to the army by a variety of professional labours, and after its close remained 
permanently in Philadelphia. Xotwithstanding the demands of a large 
practice, he found or made time for the investigation of scientific ques- 
tions, and for the publication of the results of his inquiries. His treatise on 
Diseases of the Mind, regarded as a work full of instruction, and of great 
originality by Prof. Brown, of Edinburgh, contains many practical and 
original observations, and was a valuable contribution to psychological 
medicine. It is not yet forgotten. Dr. Tuke, in his late monograph upon 
the Influence of the Mind upon the Body, quotes from it approvingly. 
Speaking of another of the essays of Dr. Rush, Dr. Tuke says: "Rush 
wrote an able essay (aud when are his essays not able ?) on Hydrophobia, 
in which he assigns an important role to the influence of fear, and an 
involuntary association of ideas.'" Few are the observers and writers 
whose labours are remembered and words quoted for a hundred years after 
they have ceased from their work. The observations of Dr. Rush on Yel- 
low Fever were extensive and important. They produced an impression 
on both sides of the Atlantic. Although their pathology was erroneous 
and their therapeutics atrocious, they were a substantial contribution to 
medical science by the stimulus which they gave to the careful and exact 
study of disease. When Rush began his lectures as Professor of the Insti- 
tutes and Practice of ^ledicine in the University of Pennsylvania, diseases 
were divided, according to the nosology of Cullen, into orders, classes, 
genera, and species, containing al)oul thirteen hundred and eighty-seven 
diseases, for each of which there was supposed to bean appropriate treat- 

' Illustrations of tlie Iiiflueuce of the Miud upou the Botly iu H< altb aud Dis- 
ea.se, by Daniel Hack Tuke, M.D., Am. ed., p. 203. 



187f).] Practical Medicine. 13t 

ment. Rush rejected these nrl)itrary divisions. He paid little rejrard 
to the name of a disease, and founded his treatment on its natnre and on 
the condition of the system. IJy this course he reduced his materia 
medica to u few active medicines, and so prepared the way for the simpli- 
tication of remedies that has been accomplished since his day.* 

Dr. Philip Synp^ Pliysick, a friend of Dr. Rush, and a favourite ])ui)il of 
that <rreat master, John Hunter, was one of the most accomplished and 
brilliant of American surpceons. He was not a prolilic writer, but lie 
found time, however, to study the character of yellow fever, and to pub- 
lish the result of his ol)servations, which were founded on post-mortem 
examinations. His researches into the character of this disease, toiJ!:ether 
with those of Rush, Ija Roche, Alonzo Clark, Jones, and others too 
numerous to mention, form a library of yellow fever literature which will 
be more fully noticed in a snbsecpient essay, and which later investi- 
gators into its nature cannot afford to ne<?lect. 

While Dr. Rush was pursuing his investigations in Philadelphia, two 
men in Boston were labouring with equal zeal and earnestness in the 
cause of medical science. One of them. Dr. John C. Warren, devoted 
himself chiefly to surgery, and his work in that direction will be noticed in 
the surgical part of these memoirs. Apart from surgery he rendered a 
service to practical medicine that should not be forgotten. By his paper 
upon diseases of the heart, he first brought distinctly to the notice of the 
profession in this country that class of affections which Corvisart described 
in his remarkable treatise. Another and more important service was the 
foundation and endowment of the anatomical museum of the medical 
department of Harvard University. Under his care and that of Dr. J. B. 
S. Jackson, who has worked in it and for it for more than a quarter of a 
century with rare intelligence and devotion, it has attained a completeness 
and excellence that few similar collections possess, and which render it 
one of the best contributions to the study and illustration of practical 
medicine in the country. In like manner, the large museums containing 
anatomical and pathological specin)ens, that have been collected in 
Philadelphia and New York and other medical centres of the United 
States, are invaluable contributions to the same science. 

Dr. James Jackson, the second labourer to whom we referred, was 
known exclusively as a physician. He was one of the founders of the 
]\Iassachusetts General Hospital, and, like Dr. Warren, was connected with 
the medical school of Harvard College at its commencement. He was a 
large practitioner, an acute and close observer of natnre, but not a pro- 
lific writer. In him that indefinable but substantial something, called 
common sense, was applied with singular success to the practice of his 
profession, to his clinical teachings at the Massachusetts General Hospi- 
tal, and to his didactic lectures at the medical school. His report on 
typhoid fever, and Dr. Hale's paper on the same disease, which may be 
found in the Communications of the Massachusetts Medical Society, were 
based on their own observations. The results at which they arrived were 
substantially those of Louis. 

Dr. Jackson's Letters to a Young Physician are models of sensible advice 
to a practitioner whether young or old, and whether living on one side 
of the Atlantic or the other. He never indulged in heroic practice, or in 
therapeutic expedients for which he could not give a reason. He believed 

' Vide Thatcher's Medical Biography. 



138 A Century of American Medicine, [Jan, 

in the conservation of nature's forces. To a larjje extent the medical 
profession of New England was moulded by his teachings and example. 
The impression which he made is not yet effaced. Such an influence, 
though difficult to describe or estimate justly, is nevertheless a real contri- 
bution to practical medicine. Dr. Nathan Smith, a contemporary of 
Rush, Warren, and Jackson, deserves also to be remembered. He was a 
sound observer, who, having enfranchised himself from the bonds of 
authority, delighted to study nature with his own eyes, and was not afraid 
to follow where she led. His essay on Typhus Fever, published in 1824, 
had the merit of pointing out the self-limited nature of that disease, and 
of showing from his own experience the futility of attempting to abort 
it, or to treat it with violent remedies. " I have never been satisfied," he 
says, "that I have cut short a single case of typhus that I knew to be 
such. Typhus has a natural termination like other diseases which arise 
from specific causes." He mentions with approbation the successful 
treatment of a physician who gave only milk and water to his patients in 
this complaint. "All that is required," is Dr. Smith's therapeutical conclu- 
sion, "are simple diluent drinks, a very small quantity of farinaceous 
food, and avoidance of all causes of irritation." This result, which he 
reached by his own observations more than fifty years ago, is the same as 
that which has lately lieen loudly proclaimed in England and Germany, 
What Dr. Smith calls typhus was undoubtedly typhoid fever. At 
the time he wrote, typhus and typhoid fever were confounded together as 
different forms of the same disease. It is worthy of remark that Dr. 
Smith recognized the fact, now acknowledged, that typhoid fever arises 
from a specific cause, and that one attack of it prevents a subsequent one- 
Typhoid fever prevails to such an extent in the United States, that our 
physicians enjoy ample opportunities for the study of it. Among those 
who have investigated it, none have done so with greater acuteness and 
ability than Dr. Gerhard, of Philadelphia, or have discriminated with 
greater clearness than he the essential differences between typhus and 
typhoid. He was the first, or among the first, to point out these differ- 
ences with scientific accuracy. He says himself: — 

"The advantages which I enjoyed of carefully studying the pathological 
anatomy and the symptoms of the two fevers, enabled me to place the question 
of their identity (typhus and typhoid), upon more settled scientific points, than 

had yet been done It is true that alter the observations, which 

formed the basis of the paper which 1 published in 1837, were collected, but 
before their publication. Dr. Lombard, of Geneva, who was of course familiar 
with typhoid fever, stated in the Dublin Journal that the two diseases were 
different; the same remark I remember to have heard Prof. Andral make on 
the authority nf Dr. Alison, and it was obvious to many persons that the 
description of I>r. Louis did not apply to the British typhus, but the points of 
resemblance and of difference were not settled, that is, they were not scientifi- 
cally demonstrated."' 

The merit of having decided this important question, of having demon- 
strated the essential difference between typhus and typhoid fever, belongs 
chiefly, if not wholly, to Dr. Gerhard, and so far redounds to the honour 
of American Medicine. Previous to his paper, which was published in 
the American Journal of the Medical Sciences, the evidence as to the essen- 
tial distinction between the two fevers was mainly speculative, or conjec- 

' A System of Clinical Medicine. By R. J. Graves aud W. W. Gerhard, 1848, p. 
735. 



1876*.] Practical Medicine 139 

tnral ;' he made it lo^fical, clear, and iitiequivocal. It is only just in this 
connection to refer to the papers of Dr. J. Baxter Upham, of Boston, 
which, published many years after the ap))earance of Dr. Gerhard's 
memoir, and founded on the careful personal investij?ation of Dr. Upham, 
confirmed the results of Dr. (Jerhard, and added to our knowledge of 
the history of typhus. The observations of Dr. Thomas Stewardson on 
remittinjr fever form a valuable addition to our knowledge of that dis- 
ease. The paper'^ which embodies his views was founded on the clinical 
study and post-mortem appearances of the cases which came under his 
notice in the Pennsylvania Hospital. In this memoir he calls attention 
to changes in the liver, which were present in every case, and were of a 
character not met with in other diseases^ These he regarded as the 
anatomical characteristic, though not the primary seat of the disease. 

Yellow fever has several times within the past century ravaged the 
Atlantic and the Gulf coast, so that our physicians have had unfortu- 
nately ample opportunities of studying, the disease. Without detracting 
from the valuable labours of many other observers, it may be stated that 
to Dr. Deveze, then resident at Philadelphia, we are indebted for beittg 
foremost in asserting and maintaining the non-contagiousness of yellow 
fever; and to Dr. Alonzo Clark, of New York, for showing that the 
pathological change, so constantly observed, in the liver, is due to acute 
fatty degeneration. 

Dr. S. H. Dickson, of South Carolina, had the opportunity of observ- 
ing an epidemic of dengue, more than twenty-five years ago, of which he 
gave a highly interesting account. He considered the disease to be the 
same as that which prevailed at the South in 1828, and as the break- 
bone fever, described by Rush in 1778. The memoir is an instructive 
and valuable one.^ 

Dr. Gerhard's labours in practical medicine have contributed materially 
to its progress, and have given him a deservedly high position among 
American medical scientists. Though our limits forbid an enumeration 
of all of his contributions, we cannot refrain from calling attention to 
his observations upon tubercular meningitis. Together with M. Rufz, 
he was the first to point out clearly the essential connection of hydro- 
cephalus with tubercles of the pia mater, and the dei)endence of the 
former upon the latter.* Previous to his investigations, the notions of 
medical men with regard to the presence and cause of water within the 
cranium, were confused, theoretical, and consequently inaccurate. By 
many acute hydrocephalus was regarded as a cause, not as an effect — as an 
independent disease, not as a result. Dr. Gerhard cleared away the ob- 
scurity, supplied the missing links, and showed that tubercular disease 
of the meninges of the brain is a distinct malady which leads to the 
effusion of liquid there, as certainly as tubercle of the lung leads to 
purulent expectoration. 

From the time of Hippocrates until recently the treatment of effusion 
into the pleural cavity has been among the opprobria med'icorum. With 
the hope of promoting the absorption of the fluid, the unfortunate sub- 
jects of it w^ere sometimes bled, covp &nr coup, sometimes salivated with 
heroic persistence, often blistered with indefatigable zeal, generally plied 

' Vide Am. .Tournal of Med. Sciences, vol. xix. p. 289, Feb. 1837 ; also, Wood's 
Theory and Practice of .Med., vol. i. p. 373. 

2 Am. Journ. Med. Sci., 1841 and 1842. 3 Charleston Med. .Journal, 1850. 

* Am. Journ. Med. Sci., xiii. p. 313; Wood's Practice vol. ii. p. 675. 



l40 A Century of American Medicine. [Jan. 

with diuretics, and by cautious practitioners treated on the expectant 
method, and all with the result of not interrupting the progress of the 
effusion. In many, perhaps in the majority of cases, the powers of nature 
were equal to the demand made upon her and the liquid absorbed. In 
a large number of cases, however, this fortunate result did not occur, and 
the effusion went on increasing until the patient was killed by mechanical 
pressure, or by the development of some disease, like tubercle or other 
trouble that the pressure induced. More than a quarter of a century ago 
Dr. Henry I. Bowditch, of Boston, whose life has been devoted to the 
study of diseases of the chest, was impressed with the notion that it 
would be possible and safe to relieve this class of cases by drawing the 
fluid off. He made several attempts to do this by means of incisions into 
the pleural cavity. The results were not satisfactory. While Dr. Bow- 
ditch was busy with these efforts, Dr. Morrill Wyman, of Cambridge, 
who, unaware of Dr. Bowditch's views, entertained similar notions, suc- 
cessfully tapped a patient, by means of an exploring trocar and canula 
with suction-pump attached. In 1850, Dr. Bowditch, aided by Dr. 
Wyman, repeated the operation with equal success upon another 
patient, using the same apparatus. " That apparatus," says Dr. Bow- 
ditch, "I have modified somewhat, so as to make it, I think, more con- 
venient; but the principle of the instrument remains as suggested by Dr. 
Wyman "^ 

From that time to the present, Dr. Bowditch has used his modification 
of Dr. Wyman's instrument for this operation. In his opinion it operates 
more rapidly than Dieulafoy's aspirator, and quite as harmlessly and 
easily for the patient. He has operated upon patients of all ages and 
both sexes, and with almost every species of complication, and has never 
seen any permanent evil results. His own statement is, that he has very 
rarely seen anything following the operation, but ease to the patient. 
During the last twenty-five years he has operated 325 times upon 204 
persons. In a large number of these cases relief was not only afforded 
to the sufferer, but imminent death was prevented. This result is a 
demonstration not only of the propriety but of the necessity of perform- 
ing thoracentesis in appropriate cases. Dr. Bowditch considers the fol- 
lowing to be the indications for the operation: — 

" 1st. To save life when immediately threatened. 
" 2d. To prolong life, even when complicated with severe disease. 
" 3d. To shorten latent pleurisy. 

"4th. To give temporary relief merely in absolutely hopeless cases. 
"5th. To relieve cases of common pleurisy which do not easily yield to 
remedies after a few weeks of treatment.''^ 

Thoracentesis is now regarded both in Europe and America as a legiti- 
mate, safe, and necessary procedure, when withdrawal of fluid from the 
chest is indicated. It has not won this position, however, without diffi- 
culty. It has had to run the gauntlet of opposition and of severe criticism 
from physicians and surgeons of great ex[)erience and reputation on both 
sides of the Atlantic. Trousseau advocated it; Valleix condemned it. 
English and American surgeons denounced it as unsafe and needless. 
That it has gradually made its way to its present acknowledged position, 
is largely due not only to the brilliant results of Dr. Ijowditclfs personal 

' Thoracentesis, a paper read before the New York Academy of Medicine, April, 
1870, p. (i, by H. I. Bowditch, M.D. 
2 Thoracentesis, ut supra, p. o. 



1876.] Prndical Medicine. 141 

experience, bnt to the earnestness with which he has pressed liv his pen 
the importance of it upon the profession, and the clearness with wliich 
he lias pointed out the proper method of performing: it." 

Tile principle of M. Dienlafoy's aspirator, an instrument too well 
known to need descri|)tion, and lately introduced to the notice of the 
jirofession, is tlie same as that of Bowditch's exploring trocar and cannla 
with suction-pump attached. The French physician's application of 
" aspiration" to all parts of the human body, is a l)rilliant generalization 
of the American physician's operation of thoracentesis. It is much to 
l>c regretted that M. Dieulafoy, in his admirable monograph on aspira- 
tion, neglected to tnake the slightest allusion to Dr. Bowditch's previous 
and persistent labours. Such a neglect on the part of M. Dieulafoy 
must have arisen either from an ignorance of Dr. Bowditch's previous 
investigations, or from a desire to claim anil wear the laurels that another 
had won. 

Consumption is recognized as the most terrible scourge of temperate 
climates. We are so familiar wtih its presence that we have ceased to 
be alarmed at its existence among us, although it causes from an eighth 
to a fifth of the total number of deaths in New England, and a very 
large proportion of all the deaths throughout the United States and 
Europe. The ablest intellects of the profession have occupied them- 
selves, and are still occupied with the study of this disease, hoping to 
unravel completely its natural history and pathology, and to learn how 
to check its ravages and ameliorate the sutfering it produces. Among 
these lal)ourers Dr Bowditch holds an honoured place. His investigations 
led him to the conclusion that soil moisture is a large factor in the pro- 
duction and development of consumption. In May, 18(52, he delivered 
an address before tlie Massachusetts Medical Society upon this subject.* 
In this address he was the first to announce what is now generally re- 
ceived as an acknowledged fact — that consumption may be produced in 
a family by residence on a damp soil. His language in the address re- 
ferred to is as follows : — 

"First. A residence on or near a damp soil, whether that dampness be 
inherent in the soil itself, or caused by percolation from adjacent ponds, rivers, 
meadows, marshes, or springy soils, is one of the primul causes of consump- 
tion in Massachusetts, probably in New England, and possibly in other por- 
tions of the globe. 

"Second. Consumption can be checked in its career, and possibly, nay 
probably, prevented in some instances, by attention to this law." 

The estimation in which these conclusions with regard to the influence 
of soil-moisture as a cause of phthisis, and of Dr. Bowditch's part in the 
investigation of it, may be inferred from the following statement : In 
1867, Mr. Simon, of England, medical officer of the Privy Council, 
presented the results of Dr. Buchanan's investigation into the death-rate 
of towns in which soil-drainage had been introduced. The latter had 
ascertained that moist towns, in which this had been done, had a less 

' Those who are desirous of consulting Di-. Bowditch's papers on the subject, 
are referred to the American Journal of Medical Sciences, April, 1S52, and Jan. 
1S63 ; American Medical Monthly, Jan. 1853, New York ; Boston Medical and 
Surgical Journal, May 25, 1857. Tlioraonnte.sis and its General Results, address 
before the New York Academy of Medicine, .April, 1870. 

2 Medical Communications of tlie Massacl)usetts Medical Society, vol. x. No. 2, 
18ti2. 



142 A Century of American Medicine. [Jan. 

death-rate from cotisnmption after doing it than before. In consequence 
of this result, Dr. Buchanan was ordered to investigate thoroughly the 
suliject. lie made " an elaborate examination of the distribution of 
phthisis as compared with variations of the soil in the three southeastern 
counties of England." Mr. Simon concludes from this investigation, 
confirmed, as he states, by Dr. Bowdilch's previous researches in Ame- 
rica, " tliat dampness of the soil is an important cause of pht/tisis to the 
population living vpon that soiV (italics as in the original). Mr. Simon 
adds, " this conclusion must henceforth stand among those scientific 
certainties on which the practice of preventive medicine has to rest."^ 

A^'llile these pages were passing through the press, a work on phthisis- 
appeared from the pen of Dr. Austin Flint, of New York, which will be 
gladly welcomed by the profession of America and of Europe. It is 
based on a careful record of six hundred and seventy cases of phthisis, 
which are grouped and analyzed with reference to the practical deduc- 
tions that may he. legitimately drawn from them. The book is written 
from a clinical stand-point. So far as practicable. Dr. Flint follows the 
numerical method of investigation. For the most part the cases, which 
he reports, are chronic in their character, and belong to a class remark- 
able for the uniform character of the lesions, and of the symptomatic 
events and laws which are develojjed by their clinical history. 

In addition to this recent work on phthi.-^is, and to other labours, which 
we have elsewhere referred to, practical medicine is indebted to Dr. Flint 
for a great deal of valuable work. His reports on continued fever, and 
articles in the A^nerican Journal of the Medical Sciences, on Tuberculosis, 
Heart Sounds, Pneumonia, Chronic Pleurisy, have all of them deserved 
and received the careful consideration of the profession. 

The progress of medicine, like that of all science, depends first upon 
the collection of facts, and afterwards upon a correct interpretation of them. 
Whoever recognizes a fact, however insignificant it may seem to him, 
and reports the discovery, makes a valuable contribution to science. The 
chief difficulty in the way of collecting accurate data, especially in 
medicine, is that few observers are gifted with the power of knowing a 
fact when they see it. " The hardest thing in the world, sir, is to get 
possession of a fact," said Dr. Johnson. Most observers report what 
they think to be, not what is. Whoever contrives a new instrument that 
increases the accuracy of physical exploration, whoever discovers a new 
method of examination, or modifies an old one, by which some secret of 
the organization is disclosed, whoever demonstrates the correct explana- 
tion of any phenomenon of the human system, whether it be the crackling 
of bubbles in the chest or the mechanism of thought in the brain, who- 
ever traces back any symptom to its cause, so as to make the former the 
pathognomonic sign of the latter, or whoever in any way, by microscope, 
analysis, scalpel, or experiment, reveals anything that pertains to the 
structure or functions of man, in health or disease, contributes to the 
progress of practical medicine. It would be pleasant, if it were possible, 
to collect all the contril)utions of this sort, small as well as large, that 
have been made by Americans during the past hundred years to medical 
science and art. While the parentage of many of these contributions is 

' Tenth Report of the Medical Offiuer of the Privy Council, 1868, p. 16. 
2 Phthisis; its Morbid Anatomy, Etiology, etc. etc. By Austin Flint, M.D. 
Phila., 1875, pp. 441, 



1876.] rractical .Medicine. 143 

well known and recognized, there are many others now incorporated 
into the body of science that cannot be traced to their discoverers ; their 
lineage is nnknown. The following pages record some of tliese contri- 
butions, in addition to what we liave already described. We are sorry 
that we cannot make the record more complete than it is. 

Dr. James Jackson, Jr., of Boston, whose premature death was not 
only a great personal bereavement to his friends, but a great loss to the 
science whose devoted student and servant he was, while pursuing his 
studies in Paris communicated in 1833 q. paper to the Sociote Medicale 
d'Observation on the subject of a prolonged expiratory sound as an early 
and prominent feature of bronchial respiration, and one which frequently 
constitutes an important physical sign of the first stage of phthisis,' The 
accuracy of this observation has been demonstrated by many other obser- 
vers since the appearance of his paper. At the present time a prolonged 
expiration, wlien heard in the clavicular region of the chest, is acknowl- 
edged as one of the earliest and most valuable signs to warn the practi- 
tioner of the insidious approach of disease. Probably few have ever 
heard even of the name of the young physician whose quick ear 6rst 
caught the sound, and whose careful observation connected it with the 
condition that produced it. 

"When Laennec made his great discovery, which has revolutionized 
the study and indirectly the therapeutics of affections of the chest, a 
variety of stethoscopes were devised to conduct the sounds of that region 
to the ear of the observer. Most, if not all, of these instruments were 
clumsy and poorly adapted to the object in view. They gradually fell 
into disuse. Direct auscultation, by laying the ear directly on the 
chest, or with a single intervening bit of cloth, yielded a better result 
than the stiff, awkward wooden tube which Laennec employed, and 
which Dr. Holmes has so cleverly satirized. Dr. C. W. Pennock, of 
Philadelphia, while making his well-known investigations with regard to 
the heart and its diseases, discarded the stiff wooden instrument and 
introduced a flexible tube stethoscope.- Its advantages were obvious. 
It did not transmit the impulse, but only the sounds of the heart and 
chest, to the ear of the examiner. While using this instrument the 
physician was able to explore the sounds of the heart and chest undis- 
turbed by any muscular movement. Dr. Caramann, of New York, im- 
proved upon Pennock's flexible stethoscope by adopting with some modi- 
fications the double binaural stethoscope of Dr. Arthur Leared, of London. 
This instrument conducts the sounds of the chest to the ear of the 
asucultator more clearly than any other, and does not conduct the 
impulse. It is the most serviceable stethoscope that has yet been 
devised.^ 

Dr. Alfred Stille,* of Philadelphia, was among the first, if not the first, 
to call attention in print to a condition of the heart observed among sol- 

' A Practical Treatise ou the Physical Exploration of the Chest, etc. By 
Au.stin Flint, M.D., second edition. Philadelphia, page 191. 

* Wood's Theory and Practice of Medicine, vol. i. p. 209. 

3 Dr. Arthur Leared, of London, exhibited at the great Exhibition in 1851 a 
double binaural stethoscope which he was the first to devise. Dr. Camraan 
evidently got the idea of his instrument from that of tlie Loudon physician, from 
which it differs in a few particulars. 

* Address before the Philadelpliia County Medical Society. Delivered Feb. 
11, 1863, by Alfred Stille, M.D. 



144 A Century of American Medicine. [Jan. 

diers as the result of prolonged and violent exertion, and now known as 
irritable heart; and Dr. Henry Hartshorne,' in the same year, more fnlly 
described the affection in a paper which he read before the College of 
Physicians of Philadelphia. 

In a commnnication forwarded in December, 18G2, to the Surgeon- 
General's Office, Dr. J. M. Da Costa^ called attention to this same car- 
diac malady to which he gave the name of irritable heart, and his Medical 
Diagnosis, published in April, 1863, contains an outline sketch of the 
disorder. A few years later'* he traced the connection of irrital)le heart 
with organic disease, and illustrated it with cases; in this paper, also, 
the inquiry took a wider scope and showed liow exertion and strain could 
result in endocarditis and subsequent valvular disease, and in hypertrophy. 
In 1871 he published a careful and elaborate clinical study of irritable 
heart* based on upwards of 300 cases, in which he showed that irritable 
heart resulted from exhausting diseases, such as fevers and diarrhoea, 
and from strains and blows, as well as from muscular exhaustion, and 
further traced the connection between functional heart disorder and 
organic change. In it was also made a valuable contribution to a more 
exact knowledge of the action of remedies on the heart.^ In 1874 he*^ 
called attention to the same affection occurring with the same sequelfe 
in civil practice. In this brief monograph the effect of cardiac strain 
upon the muscular walls, valvular apparatus, and great vessels of the 
heart, is clearly stated, as well as the general symptoms and local signs. 
These papers give an excellent account of the disease they describe, and 
make a valuable and original contribution to practical medicine. 

In a recent number of the American Journal of the Medical ScienQes,' 
Dr. Da Costa has called attention to the advantage of forced respiration 
on the part of the patient as an aid to the physician in diagnosticat- 
ing diseases of the chest. We can ourselves bear testimony to the accu- 
racy of his statement. Forced respiration is of especial service in 
doubtful cases, particularly when it is important, as it often is, to make 
out a differential diagnosis between bronchitis and phthisis. It renders 
other services than this, for an account of which the reader is referred 
to the original article. 

Dr. Da Costa has prepared, during the past twenty years, a numl)cr 
of papers, based upon his own observations of disease, which are valu- 
able contributions to practical medicine. We regret that we are unable 
to do more than allude to some of them. In addition to those which are 
mentioned elsewhere, he published, in 1855, a memoir* on the pathologi- 
cal anatomy of pneumonia. In 1859 he published the results of some 
observations® "On the occurrence of a blowing sound in the ])nlmonary 
artery, associated with affections of the lung ; on the sounds of the 
artery in health, and the effect on them and on the heart of the act of 

' Am. Jouni. Med. Sciences, July, 1864. 

2 Ibid., January, 1871. 

3 Sanitary Commission Memoirs, Medical Volume, N^w York, 1867. 
* Am. Jonni. Med. Sciences, January, 1872. 

^ These papers of Dr. Da Costa, which were based upon his army experience, 
have lately received a German translation. 

6 On Strain and Over-action of the Heart. Toner Lecture, No. 3. Washington, 
1874. ' July, 1S75. 

8 Am. Journ. Med. Sciences, Oct. 1855. 

9 Ibid., Oct. 1859. 



187(5.] Practical Medicine. 145 

respirntioii." In 1800 lie piiblislied a paper' on typhus fever, based upon 
llie cases nnder his charge, and of conrse written from a clinical stand- 
point. In 18G9 he gave to the profession a memoir on Fnnclional Dis- 
orders of the Heart;' in which he attempted to show the real value and 
meaning of a cardiac murmur. In 1871 he recorded his observations on 
Membranous Enteritis,' which, like most of his other observations, were 
based on a careful clinical study of the disease, and present a complete 
account of it. 

The importance of distinguishing the variations of pitch elicited by 
percussion is now universally recognized as an aid in ascertaining the 
condition of the organs in the chest. There are cases in which these 
variations afford the earliest clew to commencing disease ; and sometimes 
when the signs are nearly evenly balanced it throws the vote which de- 
cides the verdict. The profession are indebted to Dr. Austin Flint, of 
New York, for calling their attention to this subject, at least in this 
country. Dr. Flint's statement of the value of variations of pitch in 
exploration of the chest, and the practical inferences from them which his 
acute observation and large experience suggested, and the investigations 
which led him to his conclusions in this matter, may be found in an essay 
which received in 1852 the prize of the American Medical Association. 
The combination of ])ercussion and auscultation, or auscultatory [lercus- 
sion, as described and employed by Dr. Alonzo Clark, of New York, is 
undoubtedly well adapted to determine with ease and accuracy the 
boundaries of the heart.* This sort of cardiac examination cannot be 
made accurately without the aid of Cammann's stethoscope. When we 
recollect the method by which Piorry used to map out the boundaries of 
the heart, a task which we have often seen the distinguished French 
auscnltator undertake in the wards of his own hospital five-and-twenty 
years ago, we are forcibly struck with the advance which has been made 
during the past quarter of a century in the physical examination of the 
chest. 

There are few practitioners who have not sometimes been puzzled to 
distinguish between the solidification of pneumonia and the effusion of 
pleurisy. The differential diagnosis between these two conditions is 
sometimes a matter of great delicacy and difficulty. Here we are again 
indebted to Dr. Flint, of New York, for enabling us to solve the difficulty 
with comparative ease. He showed that. by mapping out the lobar dul- 
iiess which exists in pneumonia, the inflammatory condition of the lung 
could be discriminated from the effusion in which no such limited dulness 
exists. Though it does not fall within the scope of this paper to touch 
at all upon the subject of American medical literature, we cannot refrain 
from referring in this connection to the masterly digests of the vast num- 
ber of memoirs, monographs, and the like, upon the subject of pneumonia, 
and perhaps we should add yellow fever, which have appeared from the 
pens of Dr. La Roche and Dr. Flint. They are substantial contributions 
to practical medicine. The mechanism by which the crepitant rale of 
pneumonia is produced is not yet perfectly made out. The explanation 
of it, given by Dr. E. Carr, of Canaiidaigua, N. Y., has been accepted 
by pathologists as probable, if not fully demonstrated, and deserves men- 
tion. Dr. Carr suggests that the crepitant sound is produced by air 

• Am. Journ. Med. Sciences, Jan. 18G6. * Ibid., July, 1869. 
» Ibid., Oct. 1871. 

* New York Medical Journal, July, 1840. Flint, on Diseases of the Heart, 
Second edition, p. 43, 1870. 

No. CXLI.—Jan. 1876. 10 



146 A Century of American Medicine. [Jan. 

rushing into and distending the bronchial vesicles which had been pre- 
viously glued together by tenacious nuicns. For a full exposition of his 
views our readers are referred to his original article.' 

Croup, a name dreaded alike by physicians and mothers, was for cen- 
turies the generic term of several inflammatory affections of the throat that 
were confounded together. Gradually these different affections have been 
discriminated from each other and have received different names. The 
term croup, or as some prefer to call it, membranous croup — the diphthe- 
rite of Bretonneau — is now restricted to an inflammation of the upper 
jiart of the air passages attended with the formation of a membrane. 
The membrane is recognized as an essential part of the disease. Richard 
Bayley, Surgeon of New York, recognized the distinctive characteristics 
of this affection as long ago as 1781. In a letter to William Thornton, 
M.D., of London, which afterwards appeared in the New York Medical 
Repository,- he points out the difference between angina trachealis and 
putrid sore throat, or, in modern terms, between membranous croup and 
diphtheria. His observations were founded upon autopsies of the two 
diseases, and therefore rested on an anatomical basis. It is unfortunate 
that his views did not attract more attention, and make a more permanent 
impression than they did. They were corroborated by Dr. Peter 
Middleton, of New York, who satisfied himself that croup "is totally dis- 
tinct from the malignant sore throat ; it is not of itself of a nature malig- 
nant or infectious as the putrid sore throat may often be." These views 
were put forth nearly ninety years ago, and have been confirmed only 
within a comparatively recent period. Among those who have studied 
the natural history of this disease. Dr. John Ware deserves honourable 
mention. His memoir on the history and diagnosis of croup contributed 
materially to the accuracy of our knowledge of it and to its correct treat- 
ment. His paper was based upon a careful study of the cases which came 
under his own observation. He was satisfied that membranous croup and 
inflammatory croup were not different stages of the same disease, but dis- 
tinct maladies, differing from each other in their character and prognosis, 
and requiring a different treatment. His reasons for believing in the essen- 
tial difference of the two diseases are stated in the following moderate lan- 
guage : "The very great preponderance of fatal results in the membranous 
croup and a similar preponderance of recoveries in the inflammatory, and 
the evidence which exists that in a few cases of recovery from the Ibrmer 
the membrane has been found, and in the few cases on record of death from 
the latter that a membrane has not been found, afford strong reason for 
believing that the diseases are essentially different."'' Dr. Ware regarded 
the membrane in membranous croup more as a result of a peculiar kind of 
inflammation than as the essential part of the disease. As to the prog- 
nosis in the two forms, he inferred from his observations " that the only 
form of croup, attended with any considerable danger to life, is that dis- 
tinguished by the presence of a false memljrane in the air passages." To 
this he added the following remark: " Tiie existence of this mem- 
brane in the air passages is in a very large proportion of instances indi- 
cated by the existence of a similar membrane in the visible parts of the 
throat." As far as treatment is concerned, he was satisfied that inflam- 
matory croup gets well sooner by the aid of mild and soothing appli- 

' American Journal of Medical Sciences, New Series, vol. iv. p. 3G0, 1842. 

2 New York Medical Repository, vols. xii. and xiv., 1809 and 1811. 

3 Contributions to the History and Diagnosis of Croup, by John Ware, 1842. 



1876.] Practical Medicine. 147 

cations, such as emollient prarjrles, liglit diet, opiates, and occasional 
poiilticinj; externally, than by heroic treatment, such as openiiif? the 
jngnlar vein, free leechinp:, antinionial and other emetics and violent 
cathartics, witii which this disease has been so frequently and nnfortii- 
nately combated. In like manner it was a fair induction from his cases 
that membranous croup is more likely to be ai^^ravated than relieved by 
violent applications. He found that the inhalation of warm vapour, an 
even temperature, and enforced quiet more frequently led to the i-esolu- 
tion of the inflammation and consequent detachment and e.xpulsion of the 
membrane than tlie lancet or caustic or other extreme measures. When 
we consider that these observations were made, and the record of them 
and deductions from them published more than thirty years a<;o, and ob- 
serve how nearly they represent our present knowledge of the history, 
profrnosis, and treatment of croup, we cannot resist tlie conclusion that 
Dr. \yare was largely in advance of his time in comprehending the nature 
of croupal atfeciions, and that his observations on these afl'ections were a 
valuable contribution to practical medicine. The minute studies of recent 
German investigators in this direction have substantially contirmed Dr. 
Ware's earlier views. 

Abernetliy was in the habit of urging with great earnestness the im- 
portance, especially so far as treatment is concerned, of the constitutional 
origin of local diseases. The late Dr. Horace Green, of New York (who 
achieved such a large notoriety as a specialist in diseases of the throat), 
insisted with equal emphasis upon the local origin of constitutional dis- 
eases. His treatise on diseases of the air passages might be regarded 
without injustice as a defence of such a thesis. Its real object was, 
of course, to present and defend Dr. Green's peculiar views. Although 
his pathology and therapeutics were severely, and to a large extent, not 
unfairly criticized, both in America and Europe, yet it is not to be denied 
that his observations contributed to advance our knowledge of the throat 
and its maladies. Tliey not only stimulated inquiry, l)ut showed how far 
local applications could be carried into those regions, and to what extent 
the tissues would bear cutting, slashing, and burning. Dr. Green was a 
bold and skilled operator, an heroic therapeutist, and was sometimes 
charged with magnifying his office. These qualities enabled him to do 
what others would have shrunk from. We must remember that the 
laryngoscope, which has revolutionized our notions of the throat as much 
as Laennec's discovery did our notions of the chest, was not known when 
Dr. Green was studying and treating the air passages. Since the laryn- 
gosco|)ic mirror lias rendered visible parts of the throat that were pre- 
viously invisible except after dissection on the dead body, and has 
rendered possible a variety of local applications and operations^ that 
would not previously have been ventured upon, it has been ascertained 
that Dr. Green's attempts to reach and act upon the glottis, epiglottis, 
larynx, even down to and below the bifurcation of the bronchi, were 
legitimate. Czermak, Mackenzie, and their disciples have carried the 
local treatment of the throat and air passages much further than Dr. 
Green ever attempted, but he deserves the credit of having opened the 
way into a region which later physicians with better appliances and inge- 
niously constructed instruments have explored with such success. 

Autumnal catarrh, commonly called hay fever, from some supposed, 
but ini])robable and unproved connection with hay as its cause, has been 
recognized as a distinct disease only within a comparatively short period. 



148 A Ce.vtury of American Medicine. [Jan. 

It has undoubtedly been one of the ills flesh is heir to from time imme- 
morial, but has been confounded with ordinary catarrh, asthma, and the 
like. Gradually its distinctive features have been made out. Since it has 
obtained the status of a distinct disease, it is surprising how many people, 
both in this country and in Europe, have been found to be sufferers from it. 
Few or none die from it, and the consequent inability to obtain post-mortem 
information makes our knowledge of its pathology more or less conjec- 
tural. Dr. Morrill Wyraan, of Cambridge, whose interest in the disease 
may possibly be heightened by the fact that he is personally one of its 
victims, has contributed more than any other observer that we are ac- 
quainted with, to a correct knowledge of its natural history and treat- 
ment. His treatise on autumnal catarrh* is a classical one of its kind. He 
has pointed out the distinctive characters which separate it from other 
catarrhs, its limited duration, its remissions, intermissions, and whimsical 
variations, its intractalMJity to the action of drugs, the fact that certain 
regions are free from it and that migration to these regions relieves the 
sufferer almost immediately. He has made several experiments with regard 
to its etiology, which, while they do not demonstrate its cause, indicate the 
direction of study which wMll probably lead to the discovery of its cause, 
and has shown that "the disease has more of a general than local charac- 
ter, and falls especially upon the nervous system." By long and careful 
observation he has ascertained that the regions of this country which 
are free from the disease, the places of refuge for the catarrhly afflicted, 
are the northern side of the White Mountains in Xew Hampshire ; Mount 
Mansfield, in Vermont, and its immediate neighbourhood ; the Adiron- 
dacks, in Xew York ; the Ohio and Pennsylvania plateau, including the 
high range of land in Xew York from the Catskill Mountains to the 
western border of the State ; the island of Mackinaw ; the northern side 
of the great lakes in Canada ; tracts of land beyond the Mississippi, at 
St. Paul and in Minnesota ; the Alleghany Mountains at Oakland, and 
other elevated points of the same region ; the high lands of the interior 
of Maine ; and the whole sea coast from St. John's quite round to Labra- 
dor. It thus appears from Dr. Wyman's observations that the regions 
of safety for the afflicted are by no means small ; and that in this disease 
climate most effectually supplements the action of drugs. 

It is undeniable that during the past century, and particularly during 
the past fifty years, medical science has made great and satisfactory 
progress in acquiring an intimate and accurate knowledge of the natural 
history, pathology, and appropriate treatment of diseases of the chest 
and air passages. When we consider the contributions to this pro- 
gress made by the American physicians, Bowditch, Gerhard, Pennock, 
Da Costa, Alonzo Clark, Austin Flint, Green, 'Ware, Wymau, and 
others whose labours we have so imperfectly described, and by other 
physicians whose contributions we have not time to mention, we can 
point with honest pride to the honourable record of service rendered to 
the progress of this department of medical science by America. 

In our allusion to Dr. Xathan Smith's papers on fevers, we referred to 
his conjecture, or belief, that typhoid fever could not be broken up by treat- 
ment ; that it was in fact a self-limited disease. The best observers at 
that time were beginning to reach that conclusion. Louis' observation 
of typhoid fever led him to entertain the same notion ; Andral's study of 

' Autuinual Catarrli (Hay Fever), New York, 1872. 



1876.] Practical Medicine. 149 

typhus led liim, so far as that disease is concerned, to the same conviction. 
Doubtless there were other observers scattered here and there in Euro()e 
and America, who had learned to recognize the fact that some diseases 
were self-limited in their course, but such was not the common view. 
Dr. Jacob Bifrclow, in a paper published in 1822,' was the first or among 
the first to make a clear and distinct statement — a grand generalization 
from the study and observation of disease — that self-limilation is one of 
the laws that govern the course of a large number of morbid processes. 
This paper is not only a statement of the law, l)ut a demonstration of its 
truth. Dr Bigelow did not claim absolute originality for his views, for 
in his paper he says : " I am aware that some of the most distinguished 
French pathologists of the ))resent day incline to the opinion that many 
acute diseases, or at least inflammations, are incapable of being siiortened 
in their duration by art. The opposite opinion prevails very generally 
in this country and in England, and it would be premature to consider 
the question as decided, until it has been submitted more extensively to 
the test of comparative numerical results." That test has since been 
applied, and has resulted in confirming the accuracy of Dr. Bigelow's 
statement. We do not partake of the enthusiasm of a medical friend, who 
said that he would ratiier have written Dr. Bigelow's paper on self-limited 
diseases than to have been the victorious commander at Waterloo. Still 
the paper was one of those clear and distinct statements of a truth, or 
rather of a natural law, which, by directing the attention of physicians in 
this country and elsevvhere to a neglected and unrecognized fact, was an 
admirable contribution to the progress of practical meilicine. It has 
undoubtedly saved a great many lives by preventing useless and violent 
medication, and has saved many more by turning the attention of practi- 
tioners to the support of the system, while disease was passing through 
its appointed orbit. The observation of every year since the appearance 
of Dr. Bigelow's paper has lengthened the catalogue of self-limited 
diseases. Science is beginning to learn that the laws which govern 
morbid processes are not less immutable than those which control the 
planets ; and that therapeutics to be rational and successful must conform 
to these laws, and not undertake to neglect or thwart them. 

A superficial observation would lead to the belief that delirium tremens 
could not be an illustration of the law of self-limitation in disease. For- 
merly, according to the popular and perhaps universal sentiment of the 
profession, delirium tremens was an afifection that required prompt and 
active interference. In conformity with such a notion, the heaviest bat- 
teries of the materia medica were turned upon the unfortunate victims of 
this malady, and a rapid and unrelenting discharge of drugs kept up upon 
them. Opium, emetics, assafoetida, warm baths, digitalis, hyoscyamus, 
valerian, prussic acid, wormwood, spirits, sulphuric ether, hops, bora.x, 
and other articles were prescribed, separately or in coml)i nation, with 
extraordinary activity and zeal. Dr. John Ware, of Boston, was not 
satisfied with the results of such active and indiscriminate figiiting. He 
accordingly determined to study the natural history of the disease. In 
1831, he published a paper''^ on delirium tremens, founded exclusively 
upon a considerable number of cases of it which had occurred under 
his own observation. This memoir is an original one of marked value, 
and of special clinical interest. In it the expectant treatment during the 

' Mass. Med. Soc. Comiu. vol. iii. 

2 Trausactious of the Mass. Mei. Society, Bostou, 1831. 



150 A Century of American Medicine. [Jan. 

paroxysm is highly spoken of, and its result is stated to be a termination 
of the attack " at a period seldom less than sixty, or more than seventy- 
two hours, from the commencement of the paroxysm." This result of 
the expectant treatment as demonstrated by his observations, he com- 
pared with the results of other kinds of treatment, as reported by those 
who have tried them. The inference from the comparison is not in favour 
of active interference. " I am satisfied, therefore," says Dr. Ware, "that 
in cases of delirium tremens the patient, so far as the paro.xysm alone is 
concerned, should be left to the resources of his own system, particularly 
that no attempt should be made to force sleep by any of the remedies 
which are usually supposed to have that tendency ; more particularly tliat 
this should not be attempted by the use of opium." Since the introduc- 
tion of bromide of potassium and chloral hydrate as hypnotics, patients 
with delirium tremens have been enabled, by the aid of these agents, to 
pass more comfortably through the paroxysms of the malady, but it is 
doubtful whether the period of sleeplessness has been curtailed by them. 
The observation of more than forty years, that have elapsed since the 
appearance of Dr. Ware's paper, has confirmed the accuracy of his 
statements, and has also shown that delirium tremens is one of the dis- 
eases included by the law of self-limitation. Dr. Kuhn, of Philadelphia, 
treated this malady, nearly a century ago, after the expectant fashion^ 
in a novel way, by " confining the patient in a dark cell, and leaving the 
disease spontaneously to work itself off." After an extensive trial of 
this method he was satisfied that it yielded a good result. He experi- 
mented also with the opium treatment''' in 1783. The observations of 
Dr. Ware, which have just been cited, confirmed the earlier results of 
Dr. Kuhn. 

Medical science is largely indebted to Dr. Austin Flint, of New York, 
an observer whose acquirements, accuracy of observation, and soundness 
of judgment have justly earned for him a European as well as an Ameri- 
can reputation, for ascertaining that an affection so apparently irregular 
in its course, and so generally supposed to require active treatment as 
rheumatism, belongs to the class of self-limited diseases. A recent 
paper' of his contains a series of clinical observations on the treatment 
of acute articular rheumatism. It is not to be forgotton that Oppolzer 
instituted a similar inquiry some years ago with regard to the same dis- 
ease. The distinguished German physician felt justified by his observa- 
tions in asserting that drugs might mitigate the distress, and prevent or 
relieve some of the comi)lications of rheumatism, but could not shorten 
its natural termination. Dr. Flint's observations confirm those of Oppol- 
zer, and indicate that the rational treatment of this intractable affection 
consists in keeping it within its natural orbit, and not in vain efforts to 
curtail it. 

Recent investigations, especially those of Charcot in locomotor ataxia, 
and those of Weir Mitchell on injuries of nerves, have disclosed an 
unexpected relation between certain derangements of the spine and 
swelling of the joints. More than forty years ago Dr. J. K. Mitchell, 
of Philadelphia, was led by rheumatic or rather by rheumatoid symp- 
toms, in a case of caries of the spine, to suspect a connection between 
the medulla spinalis and the supposed rheumatism. He collected a num- 

' Phila. Journ. Med. and Phys. Sciences, iii. 242. 
2 N. A. Med. and Surg. Jouni., iv. 23f). 
s Am. Jourii. Med. Sciences, July, 1SU3. 



1876.] Practical Medicine. 151 

ber of cases besides those which carac uiidor liis own observation, and 
founded upon thcni two papers,' one of whicti appeared in 1*^31, and the 
other in 1833. His oljservations were orifjinal and valuable. Their author 
did not follow them to the lejritimatc conclusions, whiclj later investifjations 
sliow n)i<rht have been drawn from thein. Nevertheless, as far as he went, 
he was in advance of his time. Dr. Flint lias also recently published a 
paper on the natural history of acute dysentery, founded upon a series of 
cases observed and treated by himself. One of the practical conclusions 
which he drew from the study of these cases is that dysentery " is a self- 
limited disease, and its duration is but little, if at all, abridged by 
methods of treatment now and heretofore in vogue "^ 

In March, 18()4, Dr. John C. Dalton read a paper^ before the Aca- 
demy of Medicine in New York, giving an account of some observations 
which he had previously made on Trichina Spiralis. In 1869 he supple- 
mented this paper by another one* on the same sul)ject. These two 
papers not only contain an account of what was previously known with 
regard to this curious parasite, but a number of interesting original ob- 
servations upon trichinic taken from trichinous meat, and also upon those 
taken from man. The two papers are valuable contributions to the 
natural history of trichiniB and to the best method of protecting the 
system from their ravages. 

To arrange a series of facts so as to compare them with each other, 
ascertain their mutual relations, draw from them legitimate deductions, and 
thus demonstrate some unknown truth, or confirm one previously recog- 
nized, is to render as distinct a service to the cause of science as to col- 
lect the facts themselves. Indeed, the collection of facts without com- 
prehending their relations to each other and to the whole world of facts, 
is a barren service. 

Dr. Oliver Wendell Holmes, whose brilliant reputation as poet and 
novelist must not make us forget that he is also physician and anatomist, 
prepared a paper^ in 1843 upon the important subject of the contagious- 
ness of puerperal fever, a paper which belongs to the former of the two 
classes of contributions to medical science that we have just mentioned. 
The practical point which Dr. Holmes illustrated and proved is that " the 
disease known as puerperal fever, is so far contagious as to be frequently 
carried from patient to patient by physicians and nurses." The merit of 
this paper consists, not only in the collection and arrangement of the 
evidence that had accumulated upon an important matter, but in the 
logical and forcible presentation of the argument which the evidence 
legitimately warranted in favour of the point he maintained. Its value 
as a contribution to practical medicine is shown not only by the influence 
it e.xerted in this country, but also by the fact that Copland and Rams- 
botham referred to it in approving terms, and that the Registrar General 
of England made use of it in his fifth annual report. It is interesting to 
note, that at the time when Dr. Holmes' paper appeared, two works that 
were largely, if not almost universally appealed to, as authorities in this 
conntry, viz., Dewees^ 2\eatise on the Diseases of Females, and the Phila- 

' Amer. Journ. Med. Sciences, M^y, 1S31, and August, 1833. 
2 Ibid., July, 1875. 

' Transactions of the New York Academy of Medicine, 1864. 
" Medical Record, N. Y., April 1.5, ISf)!). 

5 This paper was pabli:=hed iu the New England Journal of Medicine and Sur- 
gery for April, 1843. 



152 A Century of American Medicine. [Jan. 

delphia Practice of Midwifery, by Dr. C. D. Meigs, both taught the non- 
contagionsiiess of puerperal fever. At the present time the question 
may be considered settled in favour of the view which Dr. Holmes 
deduced from the facts which were then in his possession. 

Not long after the appearance of Dr. Holmes' paper Dr. Samuel 
Kneeland, Jr., published one' on the connection between puerperal fever 
and epidemic erysipelas, in which he maintained that the two diseases 
are similar. His paper presented the evidence in favour of this view. 
Within the past year another American physician. Dr. Thomas C. Minor, 
of Cincinnati, has published a work'^ in which he enters into a careful and 
elaborate examination of the relations of puerperal fever to erysipelas, 
based upon the facts obtained from the census of the United States for 
1870. Among the conclusions which Dr. Minor felt warranted in draw- 
ing from the evidence before him are the following : — 

1st. That there is an ultimate connection existing between child-bed 
fever and erysipelas, and that in any place where erysipelas is found there 
will be found puerperal fever. 

2d. Physicians attending child-bed fever cases and erysipelas at the 
same time were most unfortunate in their practice. 

3d. Physicians having large obstetric practices, but who are known to 
be believers in the close connection of child-bed fever and erysipelas, 
returned few death certificates from either cause. 

4th. Epidemic erysipelas is invariably associated with an outbreak of 
epidemic child-bed fever, or vice versa. The London Practitioner for 
August, 1875, in a notice of Dr. Minor's work, says: " If it be asked 
what was the bond of the connection between erysipelas and child-bed 
fever here maintained, the same conclusion is suggested by the American 
as by the English experience, namely, chiefly the doctor and the 7uirse.''" 

Notwithstanding the care with which Asiatic cholera has been studied 
by competent observers in almost every part of the world, its pathology 
and treatment have not yet been clearly made out. We are indebted to 
Dr. William E. Horner, the distinguished anatomist of Philadelphia, for 
discovering one important fact with regard to it. The origin of the rice- 
water discharges in that disease had long been an unsolved problem. Dr. 
Horner first detected the fact that in cholera the whole epithelium is stripped 
from the small intestines, and that the turbid rice-water dejections, which 
are so characteristic of this disease, result from this jieculiar stripping of 
the mucous membrane. For an account of Dr. Horner's researches, 
which were made with his singular patience and accuracy, and which led 
him to tlie discovery of this pathological fact, we must refer to his ori- 
ginal article.* Here we can only call attention to his early recognition 

' Am. Journ. Med. Sciences, April, 1846. 

2 Erysipelas and Child-bed Fever, by Thomas C. Minor, M.D., Cincinnati, 1874. 

' The different departments of medical science naturally and inevitably run 
into each other to such an extent that it is impossible to draw a distinct line of 
demarcation between them. Their boundaries are fluctuating and indeterminate. 
It might be justly said that these references to puerperal fever belong more pro- 
perly to the Report on Obstetrics and Gynaecology which will appear hereafter, 
than to one which is concerned only with practical medicine. On the other hand, 
erysipelas comes cliiefly under the eye of the general practitioner. The mutual 
relations of erysipelas and puerperal fever may, therefore, be discussed as appro- 
priately under the head of Practical Medicine as under the liead of Obstetrics. 
Neither the general practitioner nor the obstetrician can afford to neglect them. 

* Am. Journ. Med. Sciences, vol. xxi. page 289. 



187G.] Practical Medicine. 153 

of it. His recognition and published record are illustrations of onr pre- 
vious statement, that American journals contain accounts of numerous 
isolated facts pertaining to the various branches of medicine which show 
that American physicians have not been idle scientific observers. The 
same observer instituted in 1827 a series of original and interesting in- 
quiries into the healthy and diseased appearances of the gastro-enteric 
mucous membrane. He endeavoured to ascertain the healthy condition 
and appearance of this membrane, its appearance in congestion from tlie 
agonies of dying, and its a])pearance in genuine red inflammation. His 
conclusions were, that congestion is not an active condition of the part 
affected, but is most frequently the result of mechanical impediment to the 
venous circulation.' Dr. Horner also instituted an inquiry into the anatomi- 
cal characters of Infantile Follicular Inflammation of the Gastro-intestinal 
Mucous Membrane, and into its probable identity with cholera infantum. 
This paper pointed out very clearly the ciianges which occur in the follicular 
apparatus.^ Dr. Horner's labours in other directions, which have given hira 
such a distinguished place among American anatomists, do not fall within 
the scope of this essay. 

The investigations of Dr. John Neill, of Philadelphia, on the mucous 
membrane of tlie stomach, made a quarter of a century ago, were original, 
and added to our knowledge of the structure of that organ. The 
results of his investigations were given to the public in a paper' en- 
tilled " On the Structure of the Mucous Membrane of the Stomach," 
which may be consulted at the present day with advantage. 

The liver has always presented an interesting and diEBcult field of study 
to the physiologist, the pathologist, and the practitioner. The problems 
which it offers to the student are far from being solved at the present day. 
While there is an agreement on many and important points among medi- 
cal scientists, there are many others which are still debated. Some of 
the ablest living physiologists and histologists, like Claude Bernard, Ch. 
Robin, Kolliker, Schiff, and others, have been led by their investigations 
to entertain and defend different, and, sometimes, opposing views of the 
intimate structure and functions of the liver. American physicians and 
physiologists have not been mere spectators of these efforts to disentangle 
and clear up such knotty questions. Dr. Leidy's paper on the compara- 
tive structure of the liver* is the most exact and complete essay in the 
department of microscopic anatomy which has appeared in any American 
medical journal, and is a most valuable contribution to our knowledge of 
the liver. 

To this we may add the researclies of Dr. Austin Flint, Jr.,^ of New 
York, upon cholesterine, which have thrown a good deal of light upon 
one of the obscure functions of the liver. According to him, says Kiiss,® 
"the e.xcrementitial product formed by the disassimilation of the brain 
and of the nerves, at the expense of protagon, is represented by choles- 
terine, separated from the blood by means of the liver, and then thrown 
into the intestinal canal. This view is based upon a number of experi- 
ments vvhicli show, moreover, that the excretion of cholesterine is in 

' Amer. Journ. of Med. Sciences, vol. i. 1827. 

2 Ibid., vol. iii. 1828. 

3 Ibid., Jan. 1851. 
» Ibid., Jan. 1848. 
6 Ibid., Oct. 1862. 

6 Lectures on Physiology, by Professor Kiiss, translated by Robert Amory,M.D., 
p. 27. 



154 A Century of American Medicine. [Jan. 

direct ratio with the nervous activity. The common expression, to feel 
bilious, seems justified by one of the elements of the bile, viz., choleste- 
rine." The connection between derangements of the liver and disturb- 
ance of the functions of the brain has long been clinically recognized. 
Whatever explains the mechanism of this connection, is as much a con- 
tribution to practical medicine as to physiology. Professor John C. 
Palton, of New York, has rendered efficient service in this direction by 
his efforts to explain the glycogenic function of the liver. Schiff and 
Pavy maintain that tiie sugar found in the liver is a post-mortem product. 
Dr. Dalton, whose experiments were conducted, to say the least, with as 
much care, ingenuity, and rapidity as those performed by Schitf, Pavy, 
or Bernard, demonstrated the presence of sugar in the living liver. The 
practical relation of his experiments and their result to the question of 
diabetes is obvious. 

Our present knowledge of gastric digestion is largely due to the op- 
portunities, which gastric fistuiae have aff"orded physiologists for the in- 
spection of the living stomach, or more exactly, of the stomach at work. 
Medical science owes a debt of gratitude to Dr. William Beaumont, 
surgeon in the U. S. Army, for leading the way in this method of ex- 
periment and observation. The subject of his experiments was Alexis 
St Martin, a French Canadian voyageur, who was wounded in 1822, in 
such a way as to produce a permanent gastric fistula. Fortunately Dr. 
Beaumont was able to keep St. Martin under his observation for a long 
time. By means of the fistula he made a series of extended, careful, and 
valuable experiments upon the digestibility of different articles of food 
and drink, and noted the behaviour of the stomach in a state of cpiies- 
cence and in one of activity. His experiments and the inferences which 
he drew from them are so well known that it is unnecessary to describe 
them here. They are not only valuable in themselves, but opened the 
way to a method of investigation, which, both in this country and in 
Europe, has yielded in the hands of various physiologists important re- 
sults to practical medicine.^ 

Dr. J. J. Woodward, now in Washington, D. C, published in 1864 a 
work on the Chief Camp Diseases of the United States Armies as Observed 
during the Present War. It is a practical contribution of great value 
to military medicine, and can be studied with profit by physicians in civil 
practice. Its account of camp diarrhoea and malarial fever are of espe- 
cial interest. 

Xo department of medical science has been studied with greater ear- 
nestness than that of the nervous system. Its importance justifies the 
labour and time expended upon it. Among American physicians and 
physiologists who have endeavoured to unravel its intricacies, Dr. S. 
Weir Mitchell, of Philadelphia, is facile princeps. He has done much 
valualde work in this direction, to which we can only briefly refer. 

During our late civil war Dr. William A. Hammond, of New York, 
himself eminent as a neuro-physiologist and neuro-pathologist, estab- 
lished, at the time he was Surgeon-General of the United States Army, 
a hospital for nervous diseases, and invited Dr. Mitchell to take charge 
of it. Drs. ]\Iorehouse and Keen were associated with Dr. Mitchell in 
the management of the hospital. The experience acquired in this hospital 
by the gentlemen in charge of it led to the publication of a number of 

' The Physiology of Digestion, with Experiments on Gastric .Tnice. by William 
Beaumont, M.D., U. S. A. The first edition of this work was published in 1S33. 



1876.] Practical Medicine. 1.55 

communications by them on nervous affections. One of the most impor- 
tant of these was entitled "Gunshot Wounds and other Injuries of 
Nerves," published in 1864. In the lanjruage of Dr. Mitchell, "this 
volume describes at lensth all the primary and secondary results of nerve 
wounds, and especially many hitherto undcscril)ed lesions of nutrition, as 
well as a novel form of burninj^ pain previously unknown, as a conse- 
quence of irunshot wounds. There are also full detjiils of treatment, and 
a report of thirty-one cases of nerve lesions." With reirard to this book, 
the Edinburgh Medical Jonrnal says that it is valuable to practical sur- 
geons, from the many details of treatment which it contains, and that it 
is "specially interestin? to physiologists and neuro-pathologists, from 
the extreme care with which the cases appear to have been taken, and 
the exactness and minuteness of the descriptions of the effects of the 
injuries on motion and sensation." "The glossy skin," previously no- 
ticed by Paget, is here described in detail, and shown in many cases to 
be connected with the peculiar burning pain that is noticed. The same 
observers put forth a paper on Reflex Paralysis in 1864. In this paper 
a novel theory of "shock" from injuries is set forth, and cases related 
where a ball-wound of one limb caused paralysis of remote parts of the 
body. 

The monograph on gunshot wounds was supplemented by Dr. Mitchell 
in 1871, by a memoir on " The Diseases of Nerves resulting from Tying." 
This was published in the medical volume of the Reports of the U. S. 
Sanitary Commission. In 1872 Dr. Mitchell published a work upon 
Injuries of Nerves and their Consequences, which he dedicated to Dr. Wm. 
A. Hammond, "whose liberal views," says Dr. Mitchell, "created the 
special hospital which furnished the chief experience of this volume." 
The work was chiefly based on the author's own observation. The British 
and Foreign Medico- Chirurgical Revieiv, in a notice of this treatise, 
says it is " the first complete treatise on the subject the English language 
has been in possession of," and adds, the volume is "written not only up 
to the present time, l)ut in many respects far in advance of it," to be re- 
ferred to now and in the future " with the utmost confidence and satisfac- 
tion." In 1874 Dr. Mitchell published a paper on post-paralytic 
chorea,' in which he pointed out the fact that organic palsies, especially 
hemiplegia, " are occasionally followed by hemichorea, or a still more 
limited local development of that disorder." In other words, his paper 
shows that " as there is a post-choreal paralysis, so, also, is there a post- 
paralytic chorea." Onr space forbids our pointing out the amount of 
original matter and suggestions which these various books and papers 
contain. As a whole they form tiie most valuable contributions to neu- 
rology and medicine in general which this country has produced. They 
are admirable as to style, logic, and ideas, and are full of suggestive hints 
and generalizations. 

Any account of American contributions to neurological science and 
therapeutics, would be incomplete without a reference to the labours of 
Dr. William A. Hammond in that direction. His investigations upon 
the physiological action of remedies will be referred to in another place. 

In his treatise on sleep'' he has added materially to our knowledge of 
the physiology of that mysterious condition, and to the therapeutics of 
insomnia. So far as priority of discovery is concerned, the credit of 

' American .Journal of tlie Medical Sciences, vol. Ixviii. p. 342, Oct. 1874. 
* Sleep and its Derangemeut!!, by Williaiu A, Hamiuoud, M.D. 



156 A Century of American Medicine. [Jan. 

ascertaining that sleep is due to a partial ansemia of the brain belongs 
to Drs. Durham and Fleming. Dr. Hammond, before he had heard of 
Durham's experiments, made similar ones, and arrived at similar results. 
His treatise, however, not only gives an account of his own original ex- 
periments upon the state of the intra-cranial circulation during sleep, but 
presents the whole subject of sleep and its derangements in a clear and 
satisfactory manner. 

A full account of Dr. Hammond's contributions to neurological science 
may be found in his recent work on Diseases of the Nervous System. Of 
this treatise the author says in his preface : " One feature I may, how- 
ever, with justice claim for this work, and that is that it rests to a great 
extent on my own observation and experience, and is therefore no mere com- 
pilation. The reader will readily perceive that I have views of my own on 
every disease considered, and that I have not hesitated to express them." 
The size of the work forbids our attempting to analyze it here. For 
any accurate notion of Dr. Hammond's peculiar views, and original ob- 
servations, we must refer those interested in the matter to the work itself. 
We desire, however, to call attention to the account which it gives of 
athetosis, a disease first recognized and, we believe, first described by 
Dr. Hammond. His description of this rare affection is illustrated by 
two cases of it, which have come to his knowledge. 

Electro-physiology, and electro-therapeutics for the last twenty-five 
years, and especially since the appearance of the treatise of Duchenne 
of Boulogne, upon those subjects, have attracted a great deal of atten- 
tion. American as well as European observers have been busy with 
efforts to discover the relations of electricity to the nervous system. By 
far the most important contribution made by any American observer to 
this subject, is the treatise' of Dr. Cliarles E. Morgan. Unfortunately 
the author died before the work went to press. H was published under 
the editorial care of Dr. William A. Hammond, who thereby bore un- 
equivocal testimony to its value. We learn, moreover, that so high an 
authority as Professor Rosenthal would gladly have undertaken the re- 
vision and editorship of this work, not only as a proof of his esteem for 
its writer, but also from his conviction of its eminent scientific value. An 
obscurity of style due partly to a lack of personal revision, and partly to 
German methods of expression, which the author's long residence and 
study in Germany had led him into, pervade the book. Whoever mas- 
ters his style and gets at his thought will agree with the editor " that there 
is nothing in the English language which at all approaches it as regards 
the scientific treatment of the whole subject of electricity." It is mainly 
physiological, only about twenty-five pages being devoted to the thera- 
peutics of the subject. The character of the results at which he arrived, 
and the stamp of his mind, may be derived from the closing paragraph of 
the book. " Such are the definite scientific applications of electricity to 
medical purposes ; of the many others it need only be said that they are 
either based on incorrect theory or diagnosis of disease, or an imperfect 
or incorrect knowledge of electro-physiology ; although I do not deny 
that future researches may enable us to do more, far more than has 
hitlierto been done in this direction." 

The New York Society of Neurology and Electrology recently ap- 
pointed a committee consisting of Prof. John C. Dalton, Dr. George N. 

' Electro-physiology and Therapeutics, Charles E. Morgan, A.B.,M.D., New 
York, 1868, pp. 714. 



1876.] Practical Medicine. 157 

Beard, and tlirec others to examine and report upon tlie existence and 
localization of motor centres in the cerebral convolutions. Tiie commit- 
tee made a number of carefully conducted and ingenious experiments 
upon dogs.' The results at which the committee arrived confirmed the 
most important of those obtained by Ilitzig and others who have fol- 
lowed him in this line of experiment. Although these and similar in- 
vestigations are purely physiological in their character, yet they have 
such an obvious bearing upon diseases and treatment of the nervous sys- 
tem that they really belong to practical medicine. 

The drugs of the Materia Medica, which are fortunately no longer 
regarded as the only or chief agents by which disease is prevented or 
combated, still justly hold an important though secondary i)lace in the 
armamenta medicorum. The contributions of America to this depart- 
ment of practical medicine during the past century have been numerous 
and valuable. Our space permits a reference to only a few of them. As 
South America does not come within the limits of our survey, we are pre- 
vented from referring to cinchona and its alkaloids, a contribution to the 
resources of medical art, American in its origin, without which the modern 
practice of medicine would be sadly crippled. Excluding this and all 
other South American medicinal products from our consideration, let us 
glance at what the United States has contributed in the past century. 
As we shall have occasion to see by and by, it has led the way in the 
introduction of one class of agents whose value cannot be over-estimated. 

Contributions to materia medica are of two classes. The first class 
comprises new, or previously unknown agents, whether vegetable or 
mineral in their origin, as veratrum viride or wild cherry, and also new 
chemical combinations, as chloroform or chloral. The second class com- 
prises researches, either clinical or physiological, into the action of medi- 
cines, by which their therapeutical power and limits are determined. 
This class of course includes experiments by vivisections or otherwise on 
animals and various sorts of chemical analyses. 

Let us glance for a moment at the first of these classes. For two or 
three hundred years previous to the beginning of the present century, 
there was a popular notion floating about in the community, especially 
in Germany and parts of France, to which physicians gave very little 
credence, tliat ergot was an oxytocic. It was commonly known in Ger- 
many by the name of multerhorn, and in this country, as well as in 
Europe, was sometimes called pulvis partiirifaciens, names that indicate 
the popular notion of its power. Notwithstanding the efforts of a dis- 
tinguished French accoucheur, Desgranges, who recognized its value 
more than a century ago, and endeavoured to bring it into use, it was for- 
gotten or not accepted by the faculty. Dr. John Stearns, of Saratoga 
County, New York, in a memoir'^ published in 1808, again called atten- 
tion to ergot as a remedy for quickening childbirth. The paper gives 
an admirable account of the article it describes, and the profession since 
its time have acquired very little additional information with regard to 
it, for Dr. Stearns not only recognized its action upon the uterus, but its 
constringing power over the small bloodvessels, through the intervention 
of the nervous system. Soon after the appearance of Dr. Stearns' paper 
other observers confirmed his statements. Dr. Oliver Prescot published 

' New York Medical .Journal, March, 1875. 

2 New York Medical Repository, 1808, vol. xi. p. 303. 



158 A Century of American Medicine. [Jan. 

in 1814 a paper,' fjiving an account of the natural history and medical 
effects of secale eoriiutiun. This paper thon<?h a less valuable contribu- 
tion to medical science, than that of Dr. Stearns, had merit enoufrh to be 
lionoured by a French translation, and an introduction into the Diction- 
naire des Sciences Medicales. The medical profession were now fully 
aroused to the value of erp^ot. The use of it spread rapidly over this 
country, and it was not lonc^ before European physicians recognized its 
virtue. It was established in the place it now holds as one of the impor- 
tant articles of the materia medica. American medical science may fairly 
claim the merit of restoring to therapeutics an agent, whose virtues 
Europe had failed to recognize. 

We have the authority of the United States Dispensatory for the 
statement, that "chloroform was discovered by Mr. Samuel Guthrie, of 
Sackett's Harbour, N Y., in 1831. At about the same time it was also 
discovered by Soubeiran in France, and Liebig in Germany " Though 
the priority of discovery belongs to the American chemist, yet it is 
evident tliat the discovery was made by each of the three observers inde- 
pendently of each other ; it is also evident that none of them had any 
notion of the anaesthetic virtue of chloroform to which we shall refer 
further on. In connection with the importance that chloroform after- 
wards attained, it is interesting to recall the language which Mr. Daniel 
13. Smith, of Philadelphia, used with regard to it in 1832. "The action 
of this ether" (meaning chloroform) "on the living system is interesting, 
and may hereafter render it an object of importance in commerce. Its 
flavor is delicious, and its intoxicating qualities equal to or surpassing 
those of alcohol. It is a strong diffusible stimulus, similar to the by- 
drated ether, but more grateful to the taste."' 

Dr. Stille, in his Tliei-apeutics and Materia Medica, makes the state- 
ment that the American Indians were acquainted with some of the virtues 
of podophyllum. At jiny rate it was fur a long time jiopularly known 
and used as a cathartic in this country before physicians employed it. 
Dr. Jacob Bigelow accurately described both the plant and its medicinal 
properties more than forty years ago. It did not come into general use, 
however, until its active principle, known as podophyllin, or more exactly 
resina podophylli, had been extracted. It is now freely used both in this 
country and in Europe, and cholagogue as well as cathartic properties 
are attributed to it. Although its virtues, have been exaggerated, as 
have those of leptandrin and gelsemium, yet all of them are valuable 
additions to the materia medica. 

The wild cherry, or prunus virginiana, is another contribution from the 
flora of America that deserves honourable mention. Its tonic and sedative 
properties were recognized more than tifiy years ago by Dr. John Eberle, 
whose Therapeutics and 3Iaieria Medica introduced to the acquaintance 
of physicians a number of articles, previously unknown or little known, 
derived from the American! vegetable kingdom. Dr. Eberle's experi- 
ments made upon himself with an infusion of wild cherry, by which he 
demonstrated its sedative influence upon the heart, deserve to be remem- 
bered not only on account of their intrinsic value, but because they show 
a recognition by him, at that early period, of the importance of making 
the physiological action of drugs the guide to their therapeutical employ- 

' A Dissertation on the Natural History and Medical effects of Secale Cornntiim 
or Ergot, by Oliver Piescot, Medical and Physical Journal, 1814, vol. xxxli. p. 90. 
2 Journal of the Phili. Coll. of Pharmacy, iv. p. US. 



1876.] Practical Medicine. 159 

meiit. Dr. GJeorge B. "Wood, of Pliiladelpliia, one of llie mo.st accom|)li,Nhed 
of American pliysicians, has pointed out in his Therapeutics and Materia 
Medica the value of wild cherry in phthisis. Some of the foreign journals 
have also recorded observations in confirmation of these statements. 

In 1850, Dr. W. C. Norwood, of South Carolina, proclaimed' in some- 
what extravagant language the sedative virtues of veralrum viride. Dr. 
Tally, of New Haven, and other American physicians had previously 
employed it, but the attention of the {)rofcssion was not generally directed 
to it until Dr. Norwood so ardently advocated its employment. Since 
that time, its active principles, viridiaand veratroidia, have been isolated, 
and they, and the phuit from whicli they are derived, have been subjected 
to a careful examination, so as to ascertain their physiological action, 
European and American i)hysicians and chemists have interested them- 
selves in this inquiry. The experiments' of Dr. H. C. Wood, Jr., of 
Philadelphia, are among the most valuable that have been made, and are 
satisfactory and conclusive. While they do not sustain the extravagant 
claims of Dr. Norwood, they demonstrate that veratrum viride deserves 
a place in the materia medica. 

As we have already intimated, we cannot undertake to give an accurate 
catalogue of the numerous articles that have been introduced into the 
materia medica from the American vegetable kingdom. We can barely 
refer to such articles as geranium maculatum, whose astringent virtues 
have a local reputation ; sanguinaria canadensis, which posseses emetic 
and expectorant properties; spigelia marilandica, whose anthelmintic 
virtues were described a century ago by Drs. Garden and Chalmers, of 
South Carolina; apocynum cannabinum, an emetic and cathartic, whose 
vulgar name of Indian hemp has led some practitioners to mistake it for 
a very different article, the Indian hemp of India ; senega or seneka root 
(introduced by Dr. Tennaut, of Virginia, in 1731), whose valuable expec- 
torant properties are recognized in Europe and in this country; serpen- 
taria or Virginia snakeroot, used by the American aborigines as a remedy 
for snake-bites, and considered by physicians of the present day to have 
stimulant, tonic, and other properties; eupatorium perfoliatum, which, 
under the less learned name of thoroughwort, is largely used in domestic 
practice; lobelia or Indian tobacco, an agent of undoubted activity as an 
emetic, a sedative, and an exjjectorant, largely used by a notorious char- 
latan and his disciples, and which possesses a value that gives it a place 
in our modern materia medica; gillenia, whose virtues as an emetic would 
enable it to replace ipecacuanha, if the latter could not be easily obtained ; 
sassafras, sabbatia, gaullheria, and a variety of other plants. These, and 
other articles that might be mentioned, are additions of greater or less 
importance to the practitioner's list of remedies. Some of them are only 
known locally ; others have travelled beyond the sea, and enjoy a trans- 
atlantic reputation. They are mentioned not only on account of their 
intrinsic merits, but to show that American physicians have not neglected 
to explore their native forests and fields, with the hope of enriching the 
materia medica of the world. 

Our account of American contributions to materia medica would be 
imperfect without a reference to the works of Dr. Jacob Bigelow 
on medical botany. In 1814 he published an octavo volume upon the 
plants of Boston and its environs. A few years later, he published his 

' Southern Med. and Surg. Journal, .June, 1850. 

2 Amer. Journ. Med. Sci., 1870, and I'hiladelphia Medical Times, vols. ii. and iii. 



IBO A Century of American Medicine. [Jan. 

American Medical Botany in three volnraes, illustrated. This was a con- 
tribution to medical science of the liijrhest order. Its descriptions are 
accurate, concise, and complete. The fifty years that have elapsed since 
its appearance have taken very little from, and added very little to his 
account of the plants he described or of their medicinal virtues. It 
still maintains its place as an authority upon the sul)jects of which it 
treats. In tliis connection the Medical Botany of Dr. W. P. C. Barton 
should be mentioned. It covers a different ground from that of Dr. Bige- 
lovv, but like his is a valuable addition to medical science. 

Let us now pass to the second class of contributions to materia medica, 
viz., clinical, or physiological researches into the action of medicines upon 
the human system. American physicians and physiologists have begun to 
cultivate this delicate, difficult, and important field of inquiry. Promi- 
nent among the explorers of tl)is region is Dr. William A. Hammond, 
of New York. His researches' upon the physiological effects of alcohol 
and tobacco upon the human sy.stem, upon albumen, starch, and gum, 
upon the excretion of phosphoric acid, and upon certain vegetable diu- 
retics have added to our knowledge of these articles. Many of the ex- 
))eriments upon which these papers are founded were made upon himself. 
His paper upon alcohol appeared nearly fifteen years ago. It was limited 
chiefly to the action of alcohol upon metamorphosis of tissue. Since its 
appearance, the well-known, laborious, and entensive researches, in the 
same direction, by Lallemand, Perrin and Duroy, Anstie, Parkes, Binz, 
Duchek, and others, have greatly increased our knowledge of the physio- 
logical action of alcohol, but have not substantially shaken the conclusions 
of Dr. Hammond. The diuretics whose action he investigated were squill, 
juniper, digitalis, and colchicum. His object was to ascertain their 
influence over the quantity of the urine, its specific gravity, and the 
amount of its solid organic and inorganic constituents. His results 
explain and confirm the conclusions with regard to the therapeutical value 
of these drugs that physicians have generally held. 

The experiments of Dr. Hammond as to the physiological action of 
diuretics upon healthy adidts, were supplemented by a series of clinical 
experiments- with diuretics by Dr. Austin P^lint, of New York. Dr. Flint 
experimented with squill, digitalis, nitrate of potassium, iodide of potas- 
sium, acetate of potassium, colchicum, and juniper. He gave these articles 
separately and in combination. His conclusions with regard to their 
action upon the solid and liquid constitents of the urine, substantially 
confirm those of Dr. Hammond. Dr. Flint modestly calls these researches 
"a small contribution to the study of the effects of diuretic remedies;" 
they are not only valuable in themselves, but at the time they were made, 
fifteen years ago, had an especial value as indicating the proper method 
of the clinical observation of remedies. 

The researches of Dr. H. C. Wood, Jr., upon the physiological action 
of drugs are admirable illustrations of the modern method of ascertaining 
their action. We have already referred to his study of the action of 
veratrum viride and its alkaloids. He has made several other similar 
contributions, which are embodied in his recent work, 77/erapeutics, 
Materia Medica, and Toxicology. This work is an original contribution 
to practical medicine. It not only presents a condensed statement of the 

' Physiological Memoirs by William A. Hammond, M.D. 
2 American Med. Monthly, New York, Oct. ISCO. 



1876.] Practical Mtdicine. 161 

author's investipcations, l)ut of the best European investigations upon the 
physiolofrical action of nietliciiies. 

In this connection, it should be mentioned, that the recent experiments 
of Dr. Robert Amorv, of Boston, and of Prof. H. P. Howditcli, of the 
same city, upon the absorption and elimination of the bromide of potas- 
sium and its kindred salts, have eulari^ed our knovvledj;e of the action 
of those remedies in this direction. Dr. J. H. Bill, U. S. A., made a 
series of experimental researches into the action and therapeutic value 
of the same article, which he published' in 18()8. The ex|)eriiuents were 
made on man. They were carefully conducted, and led him to the con- 
clusion that "bromide of potassium, in its legitimate action, is an anajs- 
thetic to the nerves of the mucous membranes and a depressor of their 
action." 

Dr. S. Weir Mitchell, assisted by Prs. Keen and Morehouse, made 
some admirable ol)servations and experiments,- at the United States Army 
Hospital for injuries and diseases of tiie nervous system, upon the antago- 
nism of atropia and morphia. They also made an examination into the 
power of conia, daturia, atropia, and morpliia to destroy neuralgic pain. 
Their observations led them to the conclusion that morphia and atropia 
act as mutual antagonists in certain of their eSects. The paper is marked 
by the care, accuracy, and completeness that characterize all of Dr. Mit- 
chell's researches. It deserves to be read in connection with Dr. Fraser's 
exhaustive researches in the same direction. 

An American, travelling in Hungary not long ago, attended some sort 
of a public meeting in one of the large towns of that region. One of the 
speakers had occasion to allude, in the course of his remarks, to Boston 
in the United States. He referred to it as a place well known to the 
audience, and distinguished not as the cradle of the American revolution, 
not for its commerce, not for its literature, not for its statesmen, its authors, 
its poets, and its theologians, not for its manufactures, not for its common 
school system, but as the place where anaesthesia by means of sulphuric 
ether wiis discovered. This discovery has rendered the name of Boston 
familiar to the dwellers on the Danube and the Caspian. Such a fact 
may not be gratifying to the vanity of Bostonians, but it testifies to the 
universal recognition of the inestimaljle value of artificial antesthesia. In 
every part of the civilized world, and wherever, in those regions called 
uncivilized, the pioneers of civilization have penetrated, in Japan, in 
China, in the islands of the sea, the power to produce anesthesia, which 
ether first revealed, is acknowledged and blessed. The knowledge of it 
is so universal, and the blessings which attended its use are so constant, 
that we are sometimes apt to tliiidc as little of its existence and |)ower 
as we do of the presence and power of light. It is impossible to estimate 
or form any adequate conception of the amount of human sutfering which 
anesthetics have relieved and prevented. To their discovery the human 
race owes the blessing that no pain follows the course of the surgeon's 
knife into any living tissue; that the accoucheur can, when necessary, 
alleviate or abolish the agonies of travail; that sleep can be procured in 
spite of any agony ; and that at the word of the physician any sufferer may 
be rendered unconscious of torture. Such a power, which John Baptista 
Porta had strangely prophesied centuries ago, which mesmerism hinted 
at, which mystics have now and then proclaimed, but which the world 

' Auier. Jouru. Med. Sciences, July, 1868. ^ Ibid. July, 18G5. 

No. CXLL— Jan. 1876. U 



162 A Century of American Medicine. [Jan. 

uever dared to expect, was shown to exist and to be capable of safe and 
easy application by the use of sulphuric ether at the Massachusetts 
General Hospital in 1846. It was, perhaps, the g-reatest contribution 
to practical medicine that the world has ever received. Of itself, it is 
enough to render American medical science honoured and memorable. 

As soon as it was generally known that the inhalation of the vapour of 
sulphuric ether would produce insensibility, experiments were made with 
various substances by physicians in this country and in Europe, who hoped 
to discover other agents, the inhalation of whose vapour would i)roduce 
anaesthesia as well as ether, or, perhaps, better than that article. The 
most distinguished of these experimenters, Sir James Y. Simpson, of 
Edinburgh, tried chloroform, a substance which was previously regarded 
chiefly as a chemical curiosity. The experiment of Sir James, naade 
upon himself, disclosed the fact that chloroform was an anaesthetic of 
great power. The iidialation of its vapour acted rather more rapidly 
than the inhalation of ether, was less disagreeable to the patient, and in 
a very small quantity produced profound anaesthesia. The knowledge 
of the discovery of this new anaesthetic spread rapidly over Europe and 
this country. The ease of its application, the profound insensibility 
which it produced, its freedom from any unpleasant odour, and the fact 
that it was discovered in Europe, while ether came from ihe wilds of 
America, and other circumstances, led to its adoption almost universally 
throughout Europe as an autesthetic in preference to ether. It was also 
used very largely in this country, but not as exclusively as on the other 
side of the Atlantic. The exi)erience of a quarter of a century has shown 
that the inhalation of chloroform is fatal in a certain proportion of cases, 
while the inhalation of ether is comparatively innocuous. 

American medical science has not only contributed to practical medi- 
cine the discovery of artificial anaesthesia, but insists that the ausesthetic, 
which it first presented to the world, is still the best that is known to 
science ; it insists upon its demonstration of the fact that pure concen- 
trated sulphuric ether is preferable, as an anaesthetic, to chloroform ; and, 
as a logical conclusion from this, it insists that the persistent use of 
chloroform by European physicians is a grave and serious error. This 
is not the place, even if we had the time, to discuss the comparative 
merits of ether and chloroform. Physiological experiments and clinical 
experience are both in favour of ether, and against chloroform. The 
prolonged inhalation of ether by man aS'ects, first, the cerebrum ; second, 
the sensory centres of the cord; third, the motor centres of the cord • 
fourth, the sensory; and fifth, the motor centres of the medulla oblongata. 
When ether kills, it does so by producing asphyxia, leaving the pulsations 
of the heart to warn the surgeon of the approach of danger — warnings 
which only the most reckless carelessness can fail to notice. Chloroform, 
like ether, afiects chiefly the brain and spinal centres; but its action upon 
the sensory and motor centres is more rapid than that of ether. Upon 
the heart it produces a steadily depressing influence. When it kills, it 
does so by cardiac paralysis, acting directly upon the heart-muscle, and 
not by asphyxia; consequently there is no warning of impending death, 
and the greatest carefulness cannot avert the fatal issue. When ether 
kills, death is due to the carelessness of the operator; when chloroform 
kills, death is due to the rashness, wilfulness, or ignorance of the operator 
in the selection of his anajsthetic. Dr. H. C. Wood, Jr., whose contribu- 
tions have been previously referred to, says : — 



1876.] Practical Mediciue. 163 

" As an ana'sthetic, chloroform possesses the lulvantagcs of qiiickness aud 
pleasantness of oi)eration, snialluess of dose, ami cheapness. These advantages 
are, however, so outbalanced by the dangers which attend its use, that its em- 
ployment under ordinary circumstances is unjustifiable. It kills without warn- 
ing, so suddenly that no forethought, or sUill, or care can guard against the 
fatal result. It kills the robust, the weak, the well, the diseased, alike ; and 
the previous safe passage through one or more inhalations is no guarantee 
against its lethal action. Statistics seem to indicate a mortality of about one 
in three thousand inhalations; and hundreds of utterly unnecessary deaths 
have now been produced by the extraordinary persistence in its use by a por- 
tion of the profession. It ought, therefore, never to be employed except under 
special circumstances, as in some cases of puerperal eclampsia, when a .^ipeedy 
action is desired, or in the field during war time, where the bulkier anaesthetics 
cannot be transported."' 

These pages have made no reference to the contributions which Ameri- 
can medical science has made during the past century to surgery, to ob- 
stetrics, including gynajcology, or to medical literature. An account of 
these contributions, and of the work of American physiologists, will be 
presented in future essays. The limited portion of the field, however, 
which we have surveyed has yielded enough of interest and importance 
to justify an honest pride on the part of American physicians in the 
work they have accomplished, and to give assurance of continued and 
zealous labour in the future. 

The l)lank pages of the book, containing all the secrets of medicine, 
which I>oerhaave bequeathed to the future, were prophetic of the work 
which medical science was destined to accomplish. The science of his 
age could inscribe only a single sentence u[)on a single page. The 
present century, whose closing hours the nation celebrates, has filled two 
or three additional pages with the secrets it has discovered, calling them 
vaccination, anaisthesia, and preventive medicine. It now transmits the 
volume to the coming ages, confident that each succeeding century will 
make new discoveries, till all of Nature's secrets are discovered, and 
then the title of the book shall be the just index of its contents. 



The discovery of artificial anaesthesia was an event of such transcendent 
importance that it becomes necessary to give a complete account of it 
in this connection. As soon as its value was established, a number 
of individuals claimed the honour of its discovery. The controversy 
which the various claimants and their partisans have carried on has been 
prolonged and sometimes bitter. Most of those who were familiar with 
the way in which the discovery was introduced to the public and acquainted 
with the claimants to it, and in a position to form an impartial and cor- 
rect opinion of the value of their claims, are no longer living. Of the 
surgeons of the Massachusetts General Hospital, who were present when 
the first operation under ether, the experimentum crucis of the new dis- 
covery, was performed, only one is now living. Fortunately that one, 
Dr. Henry J. Bigelow, the distinguished and accomplished professor of 
surgery in Harvard University, was not only present when the first ope- 
ration was performed, but was personally acquainted with most of the 
steps in the early progress of the discovery, with the claimants to the 
honour of it, and with all of importance that appertains to the history of 
it. He did more than any other living person to bring it before the med- 

' Treatise ou Therapeutics, etc., by H. C. Wood, Jr., M.D., p. 251. 



16-i A Century OF American Medicine. [Jan. 

ical public of this country and of Europe, to assert its real value, and to 
point out the best methods of utilizing it. A quarter of a century has 
elapsed since its discovery. This i)eriod is long enough for the heat of 
partisanship to cool, and to afiford an opportunity for an impartial state- 
ment, by an impartial observer, to be heard with calmness and interest. 
Moreover, the centennial anniversary of the nation's existence is an 
auspicious moment for putting on record the testimony of an intelligent 
and disinterested witness to the discovery of an agent in which the 
whole human race are interested. With the hope of obtaining from Dr. 
Bigelow a history of the discovery of anaesthesia, the following note was 
addressed to him : — 

"Dr. Henry J. Bigelow, Professor of Surgery in Harvard Universitij. 

Dear Sir : I am preparing a report on the progress of practical medicine in 
this country for the past century. In such an essay a notice of America's 
greatest contribution to medicine, modern auKsthesia, is indispensable. If you 
have the time and are willing to prepare a history of its discovery, with which 
you are so familiar, you will not only confer a favour upon all interested in it, 
but will put on record an authentic account of the discovery, by one who was 
an eye witness and actor in its early scenes, and to whose statements, on ac- 
count of their disinterestedness, great value is attached." 

To this letter the following paper was received in reply. 



A HISTORY OF THE DISCOVERY OF MODERN ANESTHESIA. 

My Dear Sir: A quarter of a century ago, your simple proposition 
would have re-awakened a discussion which had already exhausted the 
subject. Even so long ago as 1848, I thought it discreet to preface a 
paper upon the abstract question of discovery, as decided by historical 
precedent, with the disavowal of an intention to " dig up the well-worn 
hatchet of the ether controversy." But I see no objection to a review 
now — final, so far as I am concerned — of the occurrences you refer to, 
especially if I offer no opinion without its reason. 

The singular persistence of the controversy was due to a variety of 
causes. People difl'er in their views about what constitutes a discovery 
or a discoverer. A voluminous mass of sworn testimony availed little in 
those days, for want of some machinery to reach and fix a decision based 
upoa it. One of the contestants, at least, felt this, and vainly urged a 
court of justice.^ Preponderating opinions and evidence were laboriously 
and repeatedly brought to the surface by Congressional committees, and 
by other bodies and committees of those most familiar with the circum- 
stances; but, for the lack of a tribunal accustomed to estimate the weight 
and quality of scientific evidence, not to say evidence of fact, no absolute 
decision was reached. Tlie result was, that every new discussion began 
and ended like the preceding, and to as little purpose. 

When the discovery was announced (October, 1846), the circumstances 
were few and recent, and the details of its progress were known. But when 
history was obsciired, when another State, and even another >'ation, had 
set up each its own discoverer, and readers were perplexed with volumes of 
new reports and new testimony, it became less easy to sift the evidence. 
Claims, till then distinct, overlaid each other. Each alleged inventor, with 
his partisans, aimed to secure the whole honour. Opinions were pro- 

' Ste CoiiEiressional Debates for the sessions of 1S53 and 1854. 



18T6.] A History of the Discovery of Modern Anoesthesia. 165 

nouneed by people wlio knew little of the facts. Attempts were even made, 
in more than one instiince, to forestall or manufacture ])ublic opinion, by 
procurinf^ in promiscuous medical assemblies and legislatures sudden votes 
designating some discoverer by name, with a view to influence the erec- 
tion of statues. In a scientific view snch votes are not worth the paper 
that records them; but it cannot be doubted that in a free country every 
citizen has the inherent right, of which the late Lord Timothy Dexter so 
liljerally availed himself, to erect in his front yard a statue with an 
inscription. 

The claimants to the discovery are three — Dr. Wells, Dr. Jackson, 
and Dr. Morton. In discussing their claims, we cannot overlook the 
fact that the discovery was equally possible to either of them, or 
indeed to any moderately ingenious person whose attention should 
have been directed to the subject. This greatest single step forward 
in the history of medicine, like the division of the Roman printing- 
block, was a very small advance in strictly scientific knowledge. Facts 
of insensibility to pain, produced both by gas and ether, were already 
known to the world. Art needed only an extension of their application; 
and so far as art or science was involved, either Wells, Jackson, or 
Morton was competent to the work. 

This simple statement comprehends certain points of vital importance. 
The first essential recpiisite of modern an;Esthesia is, that it shall be always 
attainable, and, when attained, complete. A second requisite is, that 
the insensibility shall be safe. The discovery embraced the threefold 
and essential novelties, that it is, under propel* guidance, complete, inevi- 
table, and safe, and not, like all previous stupefaction, partial, occasional, 
or dangerous. If only |)artial or occasional, or if dangerous, neither the 
patient, the dentist, nor the surgeon would consider it of value. Even 
so late as a year after the discovery, many surgeons, and, extraordinary 
as it may now appear, some hospitals, absolutely declined to use the new 
means of producing insensibility, on the ground that it was attended with 
danger. 

Readers of the present day may not remember how surprisingly far 
previous knowledge of anaesthesia had extended. Although there has 
l3een a want of discernment in attempts to point out precisely what the 
new advance upon previous knowledge was, one great difficulty has been, 
that this advance was so small, in a strictly scientific view, that it was not 
easy to measure it. This difficulty was enhanced by the magnitude of 
the spoil, whether mere honour, or, as beyond all question it should have 
been, emolument. 

A rapid review of the history of early ana3sthesia will bring us to the 
period with which we are especially concerned. 

In the anaesthetic state, the action upon the brain may be a primary 
one, as by its compression, or by hypnotism — or secondary, as by narco- 
tic and inebriating agents absorbed into the blood, from the lungs, the 
digestive tube, the skin, or other tissues. A few extracts, abridged from 
the familiar literature of the subject, will show that surgical anaesthesia 
in these various forms has been long known and longer sought. 

Tlie use of poppy, henbane, mandragora, hemp, etc., to deaden the 
pain of execution and of surgery, may be traced to a remote antiquity. 
Herodotus ascribes to the Scythians the use of a vapour of hempseed to 
produce drunkenness by inhalation. In China, Hoa-tho, in the year 220, 
administered hashish (lUai/o) and performed wholly painless amputations; 



166 A Century of American Medicine. [Jan. 

the patient recovering after a number of days. Hashish, described by 
Herodotus twenty-three centuries ago, is the active agent of the modern 
Bhang of India. 

Pliny, who perished A.D. 79, says of mandragora: "It is drunk before 
cuttings and puncturings, lest they should be felt." Dioscorides gives 
an elaljorate method of preparing mandragora to produce anaesthesia 
(rtoisti' avaiaSridav) in those who are to be cut or cauterized — " or sawed," 
adds Dodoneus, and who in consequence "do not feel pain." Half an 
ounce, with wine, says Apuleius, a century later, enables a patient to 
sleep during amputation "without sensation." " Eruca" was used by 
criminals about to undergo the lash. "Memphitis," a "stone," so " pa- 
ralyzed i)arts to be cut or cauterized that they felt no pain." 

Theodoric, about the year 1298, gives elaborate directions how to pre- 
pare a '' spongia somnifera,^'' by boiling it dry in numerous strong nar- 
cotics, and afterwards moistening it for inhalation before operations. In 
1832, M. Dauriol, near Toulouse, cites five cases of insensibility during 
surgical operations, induced l)y him with the aid of a similar " sponge " 
It is said that persons unpacking opium have fallen suddenly. 

In 1532, Canappe described the inhaling-sponge of Theodoric, and at 
the same time warned surgeons against giving opium (d boire), which 
"sometimes kills." But in later years, and until ether was introduced, 
it was the rule to give opium before operations. 

September 3, 1828, M. Girardin read to the Academy of Medicine a 
letter addressed to his]\Iajesty, Charles X., describing surgical anaesthesia 
by means of inhaled gases. 

Richerand suggests drunkenness in reducing dislocations. Patients, 
while dead drunk, have been operated upon painlessly, and a dislocated 
hip was thus reduced after a bottle of Port wine. Haller, Deneux, 
and Blandin report like painless results in surgical and obstetric experi- 
ence. 

Baron Larrey, after the battle of Eylau, found in the wounded who 
suffered amputations a remarkable insensibility, owing to the intense cold. 
Of late years congelation has become a recognized agent of local anaes- 
thesia. 

Hypnotism is a very remarkable cerebral condition, by which surgery 
has been rendered painless. It is the grain of truth upon which the 
fallacies of mesmerism, animal magnetism, and the rank imposture of so- 
called spiritualism have been based. 

The experiments of the Grotto del Cane are familiar, as also are re- 
coveries from accidental asphyxia after complete insensibility. 

About a year ago, two healthy men, at my request, inhaled atmosphe- 
ric air from a common gas-bag. As carbonic acid replaced the oxygen, 
they both became livid, and, to every external sign, utterly insensible. 
One was really insensible ; the other nearly so, but, being a plethoric 
subject, it was deemed prudent in his case not to press the inhalation 
further. 

Nitrous oxide after a time asphyxiates, owing to the chemical combi- 
nation of its gases — on that account parting reluctantly with its oxygen. 
But it also exhilarates, and its anaesthesia is proljubly something more 
than a condition of asphyxia. 

These facts show that from time immemorial the world has been in 
possession of an anaesthesia which was occasionally resorted to, and not 
unfrequently amounted to t-omplete insensii)ility. But, as a rule, the 
following propositions held good in respect to it. 



1870.] A Tlistor}' of tlic Discovery of Modern Anesthesia. 1G7 

1st. It could not 1)0 relied on to affect everybody. 

2d. It was often insnfticient. 

3d It was sometimes danfjerons. 

What surgeons and patients needed was an inevitable, complete, and 
safe condition of insensibility ; and this they were soon to have. 

The moment arrived. In three months from Octotier, 1846, ether 
anaesthesia had spread all over the civilized world. No sinsrle announce- 
ment ever created so .2:reat and jfeneral excitement in so short a time. 
Surgeons, sufferers, scientific men, everybody, united in simultaneous 
demonstration of heartfelt mutual conjjratulation. 

It is to be res>:retted that no siuirle individual stood out clearly, at this 
time, to receive the homacje and sjratitude of the world. 

Nothiufj; like the new anresthesia had been known before. Whatever 
has been devised sin(;e has been a mere imitation and repetition of this — 
I may almost say, with no sincle substantial advantac^e over it. Our 
English friends, with a pardonable pride in matters of scientific discovery, 
not unfrequently formulate their convictions thus : "A. had indeed shown 
this, and B. that ; but it was reserved for our own C. to make the imper- 
ishable discovery." It is probable that the average Englishman still be- 
lieves that modern anaesthesia is identified with chloroform. But the 
discovery of a practicable, safe, and efficient means of insensibility had 
been made a year l)efore chloroform was thought of, and nothing impor- 
tant has been added to it since. Chloroform is at a first inhalation of an 
agreeal)le odour, more portable and less inflammal)Ie than ether, qualities 
which eminently adapt it to army use ; but it will do nothing that ether 
does not do as well, and is sometimes, though quite rarely, it is true, 
followed by fatal consequences. 

We are now to examine the claims of the three individuals mentioned, 
to the discovery of the new anaesthesia. Let us look first at those of Dr. 
Wells. And as preliminary to the examination of his claim, let us here 
revert to an interesting point in this history. It is impossible to read the 
annexed statement, familiar though it be, without renewed amazement 
that this great blessing to animal existence was distinctly offered to 
scientific men, and as distinctly neglected by them for half a century. 

The following are the words of Sir Humphry Davy, at the beginning 
of the present century ; half the century had nearly elapsed before they 
were again thought of: — 

"In one instance, when I had headache from indigestion, it was immediately 
removed by the effects of a large dose of gas" (nitrous oxyde), .... "though 
it afterwards returned, but with much less violence. In a second instance, a 
slighter degree of headache was wholly removed by two doses of gas. 

" The power of the immediate operation of the gas in removing intense 
physical pain I had a very good opportunity of ascertaining. 

"In cutting one of the unlucky teeth called denies sapientice, T experienced 
an extensive inflammation of the gum, accompanied with great pain, which 
equally destroyed the power of repose and of consistent action. On the day 
when the inflammation was most troublesome, I breathed three large doses of 
nitrous oxyde. The pain always diminished after the first three or four in- 
spirations ; the thrilling came on as usual, and uneasiness was for a few minutes 
swallowed up in pleasure. As the former state of mind, however, returned, the 
state of organ returned with it ; and I once imagined that the pain was more 
severe after the experiment than before " 

Towards the conclusion of his book he adds : — 

"^.s nitrous oxyde, in its extensive operations, appears capable of destroy- 
ing physical pain, it may probably be used with advantage during surgical 
operations in ivhich no great effusion of blood fakes p)lace." 



168 A Century of American Medicine. [Jan. 

The great discovery was here clearly pointed out to every tyro in medi- 
cine and chemistry. There vv'ere three experiments, of a completely 
original character, and with a new agent, in a direction to which con- 
temporaneous attention was not, as afterwards, leaning. Upon these an 
original hypothesis was methodically constructed and distinctly enun- 
ciated in print. It only remained for somebody to test this hypothesis, this 
guess, and to convert the guess into a certainty. But neither dentist nor 
surgeon responded, and the world for nearly fifty years attended exhilii- 
tions where people danced, laughed, and became unconscious, while hos- 
pitiil patients were undergoing amputation, alive to all its agony. 

In 1844 Horace Wells appeared, exactly repeating the hypothesis that 
Davy had printed. Wliether he got this idea from Davy, or from his 
friend Cooley, or from his own brain, is not to the purjjose. Davy had 
announced it, and the scientific world knew it. Did Horace Wells con- 
vert into a certainty the probability of Davy ? He did not. He sig- 
nally failed to do so, and, mortified by his failure, he gave np all attempts 
in that direction. More than two years elapsed, and the ether discovery 
was made and completed. Then, and then only, was Wells stimulated to 
renewed effort. But it was too late; the discovery of a surgical anses- 
thetic had been made. 

These facts deserve a careful examination. Wells had experimented in 
about " fifteen cases," and with varying success. This he states distinctly 
in his first reclamation, before his claim had expanded so as to emijrace, 
as it afterwards did, the whole anaesthetic discovery. 

He was "so much elated with the discovery" (to use his own words) 
" that he started immediately for Boston," and obtained from Dr. War- 
ren permission, as Dr. Morton, imitating Wells, subsecpiently did with 
ether, to exhibit the anoesthetic pro])erties of gas before the medical class. 
Dr. Warren was the principal New England surgeon of that day, and it was 
the obvious thing to do. This experiment, which was in tooth-pulling, wa.s 
an utter failure, and was called, as Wells says, "a hural)ug affair." He was 
completely discouraged ; went home, told his friends that the gas "would 
not operate as he had hoped," and wholly ceased to experiment, from the 
date of his failure in Boston, in December, 1844, until the spring of 1847, 
after he returned from Paris, an interval of more than two years. Wells's 
want of success can now be satisfactorily explained. He had, through 
Colton, in following Davy's instructions, made use of the traditional ex- 
hilarating-gas-bag, and of Davy's exhilarating dose. This volume of 
gas is inadequate to produce anesthesia with any certainty ; and Wdls 
failed to suggest a larger dose. This small omission closed his chances. 
He narrowly missed a great invention. Inventors, by thousands, have 
missed inventions as narrowly. 

Modern dental insensibility by nitrous oxide is unfailing, because the 
volume employed is much larger. It is also usual to exhale it into the 
atmosphere. Horace Wells had no hand in this method, of which the 
first demonstration was in a breast excision performed by myself at the 
Massachusetts General Hospital, in April, 1848, by means of about sixty 
gallons of gas, as a substitute for ether. 

From all this it will be seen that AVells did not, as has been claimed 
for him, "discover that the inhalation of a gaseous substance would 
always render the body insensible to pain during siirgiral operations,'''' 
but only that it v^'ould occasionalhj do so ; and until long alter the ether 
discovery, his experiments were not '^ surfjicul operations,''^ hut only tooth- 



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1870.] A History of the Discovery of Modern Aiifcsthesia. 109 

piillfnfj. Wells's nnnesthesia had no value to patient, dentist, or stirfreon. 
In endeavoiirinf; to trace dental an;«sthesia, as Davy had directed, from 
toothache to tooth-pullintr, his experiments unfortunately and erroneously 
showed that what availed in Davy's hands for toothache would not 
always avail for toot.h-])nllin<;. His slitiht, l)ut fatal, error of nsins^ an 
inadequate volume of *ras damacred the knowledfre of his day ; so that a 
seientilic person who had read Davy's encouraginc: and unqualified pre- 
diction, based upon his three successful experiments, would have been 
discouraged and thrown off the track by witnessing Horace Wells's 
contradictory residts. 

Wells returned from Boston to Hartford. Having hoped much from 
anJBsthesia as a money speculation, he now left it for more jtromising 
enterprises. He got up a panorama or exhibition of Natural History at 
the City Hotel at Hartford ; initiated an extensive l)usiness in the sale 
of patent shower-baths ; and somewhat largely invested in cheap copies 
of Louvre pictures painted in Paris, to be framed and sold by auction in 
this country. This carried him to Paris about December, 1S46; an 
important event in his career, as we shall presently see. 

Before he went, however, the ether discovery was made (October, 
1846), and he received from Morton the following letter : — 

'•BosTO.v. October 19, 1846. 

•' Friexd Wells. Pear Sir: I write to inform you that I have discovered 
a preparation, by inhaling which a person is thrown into sound sleep. 'I'he 
time recpiired to produce sleep is only a few moments, and the time in which 
persons remain asleep can be regulated at pleasure. Whilst in this state the 
severest surgical or dental operations may be performed, the patient not ex- 
periencing the slightest pain. I have perfected it, and am now about sending 
out agents to dispose of the right to use it. I will dispose of a right to an in- 
dividual to use it in his own practice alone, or for a town, county, or State. 
My object in writing to you is to know if you would like to visit New York, 
and tlie other cities, and dispose of rights upon shares. I have used the com- 
pound in more than one hundred and sixty cases in extracting teeth, and I have 
been invited to administer to patients in the Massachusetts General Hospital, 
and have succeeded in every case. 

'•The Professors, AVarren and Hayward. have given me written certificates 
to this effect. I have administ,ered it at the hospital in the presence of the 
students and physicians, the room for operations being as full as possible. For 
further particulars I will refer you to extracts from the daily journals of this 
city, which 1 forward to you. 

'' Respectfully yours, Wm. T. G. JNIorton." 

To this Wells returned the following remarkable and conclusive reply: — 

" Pr. Mortox. Pear Sir: Your letter, dated yesterday, is just received. 
and I hasten to answer it, for fear you will adopt a method in disposing of your 
rights which will defeat your object. Before you make any arrangements 
whatever, I wish to see you. 1 think I will be in Boston the first of next week, 
probably Monday night. 1/ the operation of acbninislering the gas is not 
afteudi'il tvitk too rnurh trouble, and will i^roduce the effect you state, it luill 
v)tdoubtedly be a fortune to you, provided it is rightly managed. 

"Yours, in haste, H. Wells." 

{A facsimile of this letter is here appended. The original is in the 
collection of the Massachusetts Historical Society.) 

Wells would not have thought that INlorton's " operation" of "ad- 
ministering" his so-called "gas" (meaning ether) would prove "a fortune" 
to him, if his own results of two years before had, in the opinion of 
himself or anybody else, any considerable anisesthetic value. 



170 A Century of American Medicixe. [Jan. 

The rest is briefly told. Wells soon after sailed for Europe, to pro- 
secute the picture business already mentioned. The distinornished 
American dentist, Brewster, resident in Paris, hearinor of his brother 
dentist Wells, sent to hira, " beirffinnr him to call on him," and asked him, 
" Are you the true man ?" " His answers, his manners," writes Brewster, 
"convinced me that he was." "Dr. Wells^s visit to Europe,^'' writes 
Brewster again, "had no connection icith his discovery, and it was only 
after I had seen the letters of Drs. Ellsworth and Marcy that t prevailed 
upon him to present his claim to the Academy of Sciences, the Academy 
of Medicine, and to the Parisian Medical Society." The quarrel of 
Jackson and Morton was Wells's opportunity, and Brewster's persuasion 
thus secured for him a European hearing. 

Thoroughly uneasy, Wells returned home (March, 1847). The world 
was everywhere ringing with ether announcements. From this period 
his claim rapidly e.x|ianded, until it embraced the whole discovery, un- 
settled his business relations, embittered his life, unhinged his reason, and 
he at last died, in New York, a sudden death, after extraordinary acts 
which led even to his arrest, but for which he could not be considered 
responsible. 

Thus perished Wells, volatile, ingenious, enterprising ; an experimenter, 
like scores of others, in the field of anassthesia, but, like them, unsuccessful 
in establishing anything of value. So far as his labours went, he left 
scientific knowledge, as well as its application to art, just about where 
Davy had left it half a century before. But he had kept the subject alive, 
and had unintentionally planted a seed in the mind of his ambitious 
partner which yielded fruit. 

We now come to the claims of Dr. Jackson and Dr. Morton ; and these, 
for convenience, we will consider together. 

It is significant that Wells, Jackson, and Morton were all in contact 
at some period of their anesthetic experiences, of which they shared in 
some degree a common knowledge. Wells, while in Boston, visited Jack- 
son's laboratory; and Jackson says that he knew of Wells's experiments; 
and it should be observed that his advice to Channing and Pealjody was 
after Wells's visit. Morton had been Wells's partner in dentistry, and 
boarded at Jackson's house In 1844 he had been a student of Jackson, 
who testifies in a certificate that he was a "skilful operator in dentistry," 
and had "studied the chemical properties of the ingredients required for 
the manufacture of artificial teeth." 

Gas and ether were long familiarly known to produce effects so simi- 
lar that whoever thought of one as an exhilarator or anossthetic must 
have thought of the other. For example while in College, in 1837, 
I twice made a gasometer of nitrous oxide, and then substituted for 
it ether, as affordinnc equal exhilaration. Brewster, in 1847, said, " It 
required neither a physician nor a surgeon to tell .... that ether would 

produce insensibility as there is scarcely a school or community 

in our country where the boys and girls have not inhaled ether, to i)ro- 
duce gayety, and many are the known cases where they became insensi- 
ble." In short, gas and ether experiences were very similar. Wells had 
been, at the outset, distinctly advised to try ether, but elected gas as less 
dangerous. If, when afterwards " disheartened by the failure" of his gas 
experiment in Boston, he remembered ether, he doubtless thought it 



18Y6.] A History of the Discovery of Modern Aiijesthesia. 171 

wonld l)e hardly worth liis while to recur to an agent so similar in its 
effects. 

In Septemlier, 1846, Jackson and Morton ]iad tlieir well-known inter- 
view. At this interview Jackson made a sufrgeslion which was soon fol- 
lowed by a discovery, and by a controversy concerning the value of this 
siigirestion. Jackson claimed that the suggestion was the whole dis- 
covery, ^[orton took the extreme opposite ground in behalf of his 
experiments. These he alone had conducted, and, while Jackson beyond 
all question kept aloof, he, recognizing their generally conceded danger, 
had gone on with them, notwithstanding, and proved what was before 
only suspected. 

The interview was briefly this; and as. it is the only point at which 
Jackson touches the progressive line of Morton's investigation, it should 
be stated strongly for Jackson. On the 30th of September, 1846, Dr. 
Morton went to the laboratory of Dr. Jackson, whom he knew well, 
having been a student under him, and recently in his house, and 
took from a closet an India-rubber gas-bag. In reply to an inquiry of 
tliat gentleman, he said, in substance (and all that Jackson claims Morton 
to have said may be admitted), " that he meant to (ill the bag with air, 
and by its aid extract the teeth of a refractory patient.'" A conversation 
ensued upon the effects of the imagination, also, among other things, of 
nitrous oxide, in producing insensibility. Jackson treated Morton's pro- 
position lightly. He told him to go to an apothecary and procirre sul- 
phuric ether — the stronger, the better — which would produce the insen- 
sibility he desired. The ether was to be spattered on a handkerchief and 
inhaled ; in a moment or two perfect insensibility would be produced. 
" Sulphuric ether," said Morton, " what is that ? Is it gas? Show it to 
me." Jackson showed him some ether, and after further conversation 
Morton went to procure it. Such was the sul)stauce of the interview at 
which Morton professed ignorance of ether, and Jackson entire knowl- 
edge of it. Jackson's knowledge and Morton's alleged ignorance we 
may now consider. 

Dr. Jackson, if we may judge from his later attitude, was not indifferent 
to renown ; nor was he regardless of the suffering of other people. He 
claims to have discovered, in 1843, that ether insensibility was infallible, 
thorough, and safe, and yet he cared so little for his reputation that he 
did not publish his discovery; and he forgot his humanity so far, that he 
allowed patients, the world over, to encounter the agonies of amputa- 
tion during four years more. This extraordinary circumstance cannot 
strengthen belief in the fact of the discovery at this early date. 

In a long communication to Humboldt, in 1851, and in certain other 
communications to learned foreign societies and individuals, Jackson lays 
great stress upon the elaborate mental process which enabled him to 
construct, in 1842, an hypothesis of insensibility, based upon the dis- 
tinct functions of nerves of motion and sensation, superficial and deep 
sensibility, etc. But the more studied and complete this hypothesis, 
and the more circumstantial the evidence of its careful elaboration, the 
more remarkable is it that it was laid on the shelf for four years. With- 
out questioning the entire honesty of Dr. Jackson's convictions, it is 

• It is to be observed here, that, if the patient was intelligent enough to obey 
instructions, and if Morton really meant to administer air, the patient would have 
become insensible by asphyxia. (See p. 166.) 



112 A Century of American Medicine. [Jan. 

safe to say that it is difficult to measure the original strength of any belief 
which has lain dormant for four years, especially if tliat belief has since 
proved to be a valuable truth. Dr. Jackson claims, indeed, to have men- 
tioned his hypothesis to several persons during this interval ; but this 
testimony, if carefully examined, relates chiefly to a narrative of his chlo- 
rine gas experiences. In fact, some of Dr. Jackson's immediate family 
had, dnrins: this same interval, in 1844, submitted to painful tooth • 
extraction by Morton, and yet no anaesthesia was mentioned then. The 
hypothesis seems to have had for several years a precarious existence. 

The only striking testimony is that of Peabody, a pupil, who was ad- 
vised by Jackson to employ ether in having a tooth drawn, but who, 
after consulting his father, an accomplished amateur chemist, was deterred 
from doing so by the reputed danger, which Jackson's suggestion did not 
outweigh. But this advice was a year after Wells's experiments and 
failure in Boston, and his conversations at that time with Jackson. 
Whenever tooth-pulling was brought to Jackson's notice, how could he 
fail to think of Wells's experiments with gas? And who could think of 
gas as an inel)riator, without its co-inebriator, ether ? the obvious and 
only possible conclusion being, that what gas had done, ether might do, 
namely, sometimes succeed and sometimes fail. I have no douI)t that 
this thought did occur to Jackson's mind when tooth-pulling happened 
to be talked of, especially after Wells's experiments. 

It also occurred to Morton's mind. He knew more of Wells and of 
his varying experiments than Jackson did, and there is no question that 
Morton the dentist, oftener than Jackson the chemist, dwelt upon pain- 
less dentistry. His business was " mechanical dentistry," making sets of 
teetli ; and he was daily suffering in purse because patients feared to have 
their teeth drawn. " I will have some way yet," said Morton to Gould, 
in August or September, 1846, a short time before the discovery, "by 
which I will perform my operations without pain." "I smiled," replied 
Dr. Gould, " and told him, if he could effect that, he would do more 
than human wisdom had yet done, or than I expected it would ever do." 

Who that remembers the late Dr. Gould, cautious, accurate,' truthful, 
judicial, the friend and brother scientist of Dr. Jackson, will doubt this 
sworn testimony ? It was Dr. Gould, who, when his wife told him of 
rumors that Dr. Morton had drawn a tooth without pain, under the in- 
fluence of something inhaled, exclaimed, " Yes, that can be done ; ether 
will do it." So obvious was the transition from gas inebriation to ether 
inel)riation, from gas insensibility to ether insensibility, in the mind of 
one who happened to have his attention drawn to the subject of anaesthesia 
by inhalation. 

Morton knew of gas, and of Wells. He was in eager pursuit of 
awfesthesia. He believed in it. If he knew, also, of ether, he was, in 
all human probability, on the verge of discovery. Did he know of ether ? 

It is fortunately established beyond all question that Morton made 
long inquiries about ether in July, and also, a short time before the Octo- 
ber experiments. If we reject the evidence of Wighiman and ^letcalf 
on this point, both of them disinterested, accurate, reliable, we must 
reject all human testimony. 

Wightman the philosophical instrument-maker, afterwards Mayor of 
Boston, narrates a long conversation with Morton in the cars, when 
moving his family from his country residence to Boston. During this 
conversation he informed Mrs. Wightman, who asked him who Dr. Mor- 



1876.] A History of the Discovery of .Modem Antcsthcsia. 173 

ton was, "that lie was a dentist wlio was ex|>erimentiiig upon the relief 
of pain in dental operations." Wightniau fixes the date, Sei)leniber 28th, 
of this journey, by items of expense eharged in his day-book, of which 
the leaf was produced, as part of his sworn testimony. This enables hira 
to tix the time of several previous conversations with ]\[orton, concerning 
mesmerism, the eflects of the imagination, etc., and especially of one as 
to whether rnl)ber or oiled silk bags would hold "common ether." 

Metcalf, the well-known apothecary, a scrupulously conscientious wit- 
ness, equally substantiates the date of a conversation half an hour long, 
about ether, with Morton, who held in his hand a bottle of it which 
he had brought with him. In this conversation, " entirely about the in- 
haling of ether," interspersed with anecdotes of exhilaration and insensi- 
bility, Metcalf.told Morton of "a person to whom he had given it, who 
was exceedingly wild, and who injured his head while under the influence 
of it, and did not know, when he got over the influence of the ether, that 
lie had hurt himself, until it was called to his attention." "Morton," Met- 
calf testifies, "when he went away, knew as much about it as I did, for I 
gave him all the information which I had." Metcalf sailed for Europe in 
July, 1846, just after this conversation. While in Italy, in the early 
part of 1847, he took up a newspaper announcing the discovery, by a 
Boston dentist, of insensibility through ether inhalation. "I said at 
once," testifies ^letcalf, " that I was sure Morton must be the man, for 
be was engaged upon ether before I left home ; and that I now knew 
why he had been so curious, and at the same time shy, in his conversa- 
tion with me." To those who know Mr. Metcalf this evidence has all 
the weight of personal experience. 

There can be no question that Morton knew about ether. How much 
he knew about it is less important. But it should be mentioned that 
he claims to have made repeated experiments with it upon animals in 
the summer of 1846. 

Morton's explanation of his professed ignorance of sulphuric ether 
was this. During the summer, while boarding at Dr. Jackson's, he 
had lieard frequent and protracted expositions of Jackson's claim to the 
invention of the electric telegraph, then recent, and the important fea- 
tures of which Jackson was satisfied he had communicated to Morse 
during an ocean passage. Dr. Jackson had, indeed, a well-stored and 
suggestive mind, which made it more than likely that he had furnished 
information, of which Morse, while originating and mentally evolving a 
system of electric telegraphy, may have been glad to avail himself. A 
sharp public discussion, witli pamphlets, ended with a verdict in Morse's 
favour. In going to Jackson, Morton feared that if there were any de- 
liberate conference, Jackson might set up a similar claim of participation 
in his own search for painless dentistry, and therefore took the shortest 
way to exhaust his knowledge for his own benefit, without discus- 
sion. There can be little doubt that Morton was in this matter reticent, 
as Metcalf states, and intended to keep it a secret from his brother 
dentists. I am also inclined to believe that Morton at first cared little 
about the abstract question of discovery, and would have willingly left a 
large share of any honour unquestioned in the hands of Jackson. But 
when Jackson made a claim upon the patent, and the profits, beyond the 
amount to which Morton conceived him to be entitled, then he deliiied 
his own claim to the discovery. It may be stated in this connection, 
that the surgeons of the Massachusetts General Hospital, who had no 



174 



A Century of American Medicine, 



[J an. 



interest whatever in this difference, and could liave none, were friends of 
Jackson, and stranjjjers to Morton. They yielded, when it became neces- 
sary to take sides, only to their deliberate conviction of the justice of 
Morton's claim. 

It will be advantageous, at this point, to take a general view of the 
" ether controversy." For this purpose, I find I can do no better than 
to quote the following letter, written, when the occurrences were fresh, 
to the Hon. Robert C. Winthrop, in Washington : — 

January 26. 1848. 
Dear Sir; I believe most fully, that Dr. Morton deserves any reward Con- 
gress may grant to the discoverer ; because, although many people have 
thought that a man could be intoxicated beyond the reach of pain. Dr. Morton 
alone proved this previous possibility to be a certainty, and safe. A diagram 
will make the matter plainer than words : — 



Before October, 1846, who 
m.ide tbe suggestion ? 

Here is the only ground 
of dispute. 



Discovery in Oct. 1846. 
Consecutive experiments by 
Morton. 



After October, 1846, Mor- 
ton alone took the responsi- 
bility of danger, and proved 
that it was 

1st. Certain. 

2d. Safe. 

The two last points, namely, the consecutive e.xperiments, and their confirma- 
tion, which nobody disputes to Morton, make him, in my eyes, the discoverer. 
'I'he only doubt is, who made the suggestion ? To me this is of no importance. 
Dr. Jackson says, "I did. I told Mr. Morton to try the experiment; and 
unless I had so told him, he would never have tried it." Dr. Jackson adds : 
" I first tried ether when I was suffering from chlorine, in 1842. I afterwards 
recommended it to Mr. Peabody." But Dr. Morton confutes even these posi- 
tions. He says to Dr. Jackson : " 1st. I show, by the evidence of Dr. Gould, 
Mr. Wightman, and Mr. Metcalf, that I was experimenting with ether before 
the interview in which you claim to have brought it to my notice. 2d. In 1842 
you only re-discovered what was before clearly in print in Pereira's Mcderia 
Medica. 3d. You claim that you told Mr. Peabody what you knew of ether. 
Now you could not know it. You have stated all your grounds of deduction, 
and the widest inference you could draw from them is, a suspicion of the pro- 
perties of ether; and a suspicion in science, an unconfirmed theory, amounts 
to nothing. Finally, what you claim to have discovered in 1842 you kept to 
yourself during four years. Do you expect the world to believe you knew its 
value? Do you expect it to reward you for letting people suffer during that 
length of time? Besides, the suggestion of anajsthetic agencies occurred to 
Davy; especially was it followed out, though unsuccessfully, by Horace Wells, 
who, disgusted with failure, abandoned his attempts." These and others had 
hypotheses as well as Dr. Jackson. Morton alone proved the hypothesis. 
Without Morton there is no evidence that the world would have known elber 
to the present day. I believe this covers the ground of important argument 

and difference in the pamphlets 

Respectfully your ob't servant, 

Henry J. Bigelow. 

At the interview referred to, Jackson's partisans tenaciously insist 
that he assumed direction, as a physician might have done, of tbe admin- 
istration of a remedy ; wdiile Morton acted only as a " nurse." Let us 
examine, then, the often-quoted " nurse" argument with which the oppo- 
nents of Morton have endeavoured to handicap him at the outset. Here 
is its fallacy. A physician, by common understanding, possesses a posi- 
tive knowledge of the effect of his remedies, in advance of their admin- 
istration. Such knowledge was impossible to Jackson. Again, a phy- 
sician is employed expressly to direct, and a nurse to obey. Under 



1876.] A History of the Discovery of Modern Aiiiusthesia. 175 

these circumstances a nurse is not lil<ely to get much credit for original- 
ity, which is in fact absolutely excluded by the terms of her coniract. 
Tliere was no such contract here. Morton was not a mere agent, with- 
out preconceived i)Ian, automatic in action, and irre8i)onsible as to 
results. On the contrary, he was already conducting an independent 
investigation. He was in jmrsuit of ana\stliesia when he went to the 
laboratory of Jackson, with whom the sul)ject, even admitting his claim, 
had slumbered for years. He had been before, and in the same way, to 
books, apothecaries, instrument-makers, in short, to various usual and 
available sources of knowledge, as is customary with every investigator 
or discoverer. The purpose, the invesiigatiou, the patient, the discre- 
tion, the responsibility, were all his. Morton was not a "nurse." 

Morton had a combination of qualities such as few other men in the 
community possessed. Fertile in expedients and singularly prompt in 
execution, he was earnest and persevering beyond conception. His de- 
termined persistence is remembered even at this interval of time, as 
having been a terror to his best friends. Nobody denies that Morton, 
recklessly and alone, faced the then supposed danger attending ether 
stupor. If all accredited scientific opinion had not been at fault, and in 
the case of any fatal result, he would have infallibly been convicted of 
manslaughter, with little probability that anybody would have come 
forward to say, "The responsibility is not his, but mine." 

In fact, Dr. Jackson endeavoured at this time, by word and deed, to 
keep both himself and his reputation clear of Morton, as a reckless and 
dangerous experimenter. The only operations under ether witnessed by 
him during the first three months were on November 21, 1846, and 
January 2, 1847 ; and a part of this time he was absent from the State, 

" But," it has been a hundred times said, " Jackson made a suggestion, 
and Morton used it." It is evident that we cannot escape some discussion 
of the relation of "suggestion" to "discovery," no matter how little 
the suggestion may be intrinsically worth, or how fortuitous its success. 
The simple question is, What was the actual value of Jackson's sug- 
gestion to Morton at the time it was made — I distinctly mean before 
Morton had handled it ? 

A suggestion in science varies in value as much as a suggestion 
in common life, where advice is not always sound advice. It may, indeed, 
turn out fortunately, like a suggestion, for example, to wager money on 
the ace of spades. But because it may prove so, the advice does 
not necessarily imply merit in the adviser. This is an extreme case. 
At the other extreme is a mathematical certainty, such, for example, as 
that twice two make four : a truth the value of which is not afterwards 
augmented for intelligent people by a material test or demonstration that 
twice two a|)ples make four apples. A similar example of mathematical 
certainty is that calculated by Leverrier (liable only to the instrumental 
fallibility of dividers, telescopes, and equations), which did not become 
more absolute, nor more true, when Galle saw the planet where Leverrier 
told him it must be. Mathematics are unerring, while predictions in 
physiology are as uncertain as predictions about the weather a week 
hence. Yet it has been argued that Jackson was Leverrier, and Morton 
Galle. 

Jackson's alleged hypothesis, before Morton took hold of it, had only 
the value of a lottery ticket, which, through Morton's unaided, dangerous, 
and acknowledged efforts, drew an immense prize — or of "the cast of a die" 



176 A Century of American Medicine. [Jan. 

— "for in that light," says Watt, whose name is identified with the his- 
tory of steam, and the soundness of whose practical views no one will 
dispute, "I look upon every project that has not received the sanction of 
repeated success." A statement of the grounds upon which this view is 
based will enable others to draw their own conclusions. Let us begin 
with Jackson's experiments. 

" Having, in 1841-2," says Jackson, "got my lungs full of chlorine 
gas, which nearly suffocated me, I immediately had ether and ammonia 
brought to me, and alternately inhaled them, with great relief." The 
next day, still suffering, and " perceiving a distinct flavour of chlorine 
in my breath," the experiment was repeated " with perfectly pure washed 
sulphuric ether," and " with entire loss of feeling." "All pain ceased." 
He " fell into a dreamy state, and became unconscious of all surrounding 
things." 

In other words, he inhaled ether, until, seated as he was "in a rocking- 
chair, with his feet in another chair," he fell asleep. So far there was 
nothing new. Pereira, for example, says {Elements of Materia Medica, 
etc., London, 1839, pp. 210-211):— 

"The vapour of ether is inhaled in spasmodic asthma, chronic catarrh, and 
djspucea, whooping-cough, and to relieve the effects caused by the accidental 
inhalation of chlorine gas." " When the vapour of ether sufficiejitly diluted 
ivilh atmospheric air is inhaled, it causes irritation about the epiglottis, a sen- 
sation of fulness in the head, and a succession of effects analogous to those 
caused by the frotoxide of nitrogen (vide p. 1.50), and persons peculiarly sus- 
ceptible to the action of the one are also poioerfully affected by the other. [Juurn. 
Science, vol. iv. p. 158.) If the air be too strongly impregnated ivith ether, 
stupefactio7i ensues." 

Such was contemporaneous knowledge. Jackson's experience was 
identical with that recorded by Pereira. And Pereira further distinctly 
calls attention to the similar effects of inhaled gas and inhaled ether, and 
to the stupefaction caused by ether. 

Pereira adds, in regard to the danger of this condition : — 

"In one case this state continued, with occasional periods of intermission, 
for more than thirty hours ; for many days the pulse was so much lowered that 
considerable fears were entertained for the safety of the patient. [Op.c/t.) la 
another case, an apoplectic condition, which continued for some hours, was 
produced." 

I shall revert to this subject of danger. 

But Dr. Jackson alleges that he now advanced a step further, and 
logically inferred the entire Siifety and inevitable certainty of ether anaes- 
thesia, in all cases, and during the severest surgery. This was an un- 
warrantably wide inference, as we shall see. 

Further still. Dr. Jackson claims to have invented a method upon which 
the success of his hypothesis largely, as he suj»[)Osed, depended; and he offers 
this method as evidence that he made the hypothesis and the discovery. 
It is plain that a discovery may be in this way rendered more probable. 
Whoever is in possession of a new method is more likely to find the way 
to a nevv truth. But if the alleged method proves to be partly erroneous 
and partly an old and familiar matter, then the proof of alleged discovery 
is no stronger because of it. In fact, just so far as the hypothesis was 
apparently stronger by reason of the method, it becomes weaker when 
the method falls to pieces. Let us, then, examine this alleged method. 

Dr. Jackson has from the first insisted upon two points, as peculiar to 



1876.] A History of the Discovery of Modern Anaesthesia. 177 

his invention, and essential to his discovery. By these safety and cer- 
tainty are stcnri'd, and a neglect of them explains i)revious uncertainty 
and danger. They are, 

1st. Purity of tlie ether ; 

2d. An admixture with it of atmospheric air 

If these conditions arc either not essential or not new, we find ourselves, 
at least so far as method is concerned, where Pereira left us. 

From time immemorial, the familiar way of inhaling ether has been 
with air from a handkerchief. Pereira, as before quoted, distinctly stipu- 
lates for air. Says another writer, "Animals breathe oxygen. AVithout 
oxygeu a man must die. Ether would not have saved Desdemona." This 
needs no ghost for its enunciation. But the fact is, in etherizing by a 
sponge or cloth, the difiiculty is as often to exclude air enough as to 
admit air enough. Some good authorities maintain that there is advan- 
tage in its exclusion — that the insensibility from gas, for instance, is due 
to asphyxia. Even in etherizing, they aim to take advantage of this con- 
dition by restricting the air supply. The French ether-bag, still in use, 
is expressly arranged for this purpose. In short, while it requires espe- 
cial effort to exclude air, partial asphyxia is not dangerous; and a claim 
to the discovery of the safety or certainty of ether stupor based upon the 
admission of air cannot stand. 

A claim based upon pure ether is equally void. Tolerably pure ether 
is better, but by no means essential, for safe insensibility. The specific 
gravity of pure ether is not very far from 0.718, and is difficult to attain; 
that of our usual inhaling ether of Powers & Weightman, 0.724 ; and of 
Squibb (fortior) about the same. The ether of the old Pharmacopoeia, 
and of the shops in the year 1840, was not far from 0.750 ; and this is a 
very practicable anaesthetic. Its slight adulteration with alcohol and 
acid is not especially deleterious, when inhaled. In fact, anaesthesia re- 
sembles dead-drunkenness, which is equally possible with brandy, or with 
brandy and water. The real danger was not from impure ether, but from 
over-inebriation — a danger which exists to-day with the best ether. 

The discovery was not in the admission of air, nor in the use of a 
particular quality of ether. It was, that the inhalation of ether, which 
had been familiarly resorted to for years, could be prolonged beyond the 
usual stage of exhilaration to a stage of stupor, possessing the complete 
insensibility of a dangerous coma, yet, unlike that condition, safe; and 
that all this could be effected in every case. 

The history of ether anaesthesia was the gradual discovery of the fol- 
lowing facts : — 

1st. That ether inhaled produced, capriciously, in certain instances, 
unconsciousness. (Old.) 

2d. That it possessed the power of producing stupor in every case, 
(^^ew.) 

3d. That this stupor could be exactly graduated as to time. (New.) 

4th. That it could be increased or diminished, and arrested short 
of danger, and so made safe. (New.) 

5th. That there were certain infallible indications of danger. (New.) 

6th. That, while thus controllable and safe, it could be made at will so 
profound that even amputations should not be felt. (New.) 

All that is new belongs to Morton. 

A person inhaling ether from his handkerchief would drop it when his 
hand and senses were benumbed. As air entered the lungs he would 
No. CXLI.— Jan. 1876. 12 



ns A Century of American Medicine. [Jan. 

revive. Such was Jackson's self-experiment, already covered by Pereira. 
But a second person, who should now seize the handkerchief and compel 
the continued inhalation to the stage of stupor, mijjlit obviously make a 
valuable study of this new ground. He could draw his patient's tooth, 
or amputate his leg, and thus measure the insensibility. He could repeat 
the experiment until satisfied that insensibility could be always attained, 
and that it was safe. All these experiments M(jrton tried upon others, 
and when he had tried them the discovery was made. 

Jackson virtually chiims that his inference extended to the universal 
efficacy, the completeness, and the safety of the stupor. 

Of the universal efficacy of the new stupor Jack>on could have no 
valuable opinion. Such knowledge was possible only through observa- 
tion of many cases, with an experience which could say, "Administer 
ether as for exhilaration. Protract its inhalation beyond this usual stage, 
and you will inevitably reach an ulterior condition of stupefaction. During 
this process a patient may struggle with a giant's force ; or perhap.b will 
tell you of his extreme distress ; or after five or ten minutes of inhalation 
will satisfy medical bystanders, as patients sometimes do now, that he is 
not amenable to ether. Another will assure you, with apparent reason, 
that he is dying; or, livid with asphyxia, will comi)ress his lips and cease 
to breathe; or may, for a long time, alternate between lividity with a 
failing pulse, and arterialization with a partial return of consciousness,' 
But, through all these apparently alarming indications, urge the pro- 
cess discreetly, and you will ultimately and inevitably reach a stage of 
stupefaction." 

Dr. Jackson could not say all this, because he knew nothing of it; nor 
did anybody else, until Morton established the fact that there was no 
exception to the potency of ether. These and other contingencies, once 
startling, still occur with the best ether, and the experience of a quarter 
of a century. Had Morton been a timid or a discreet man, anaesthesia 
might have been delayed beyond the present generation. Morton com- 
pelled inhalation in spite of indications to arrest it, incurred the respon- 
sibility of doing so, and is entitled to the credit. 

The convpleteness of the insensibility — its adequacy, for example, in am- 
putations — was settled only by repeated observation, with varying results, 
but gradually accumulating evidence : from the tooth first jiainlessly ex- 
tracted, through several failures to comparative success in dentistry ; then 
the removal of a venous tumour of the jaw, where the patient was doubt- 
fully insensible; then a fatty tumour of the arm, with complete insensibility ; 
and finally, after an inconsiderable operation or two, the amputation of a 
leg, practically successful. Everybody awaited this final test by ampu- 
tation, and then only was the accumulated evidence deemed conclusive. 
It was, indeed, beginning to be felt that the process was a safe one, and 
that it promised satisfactory results ; otherwise the hospital surgeons 
would not have permitted this test of it in a patient weakened by disease. 
But this experiment, like the rest, so fiir as ansesthesia was concerned, 
was Morton's, and a part of his well-organized enterprise to investigate 
and estal)lish the new insensibility. As this amputation has been repeat- 
edly iiublished as mine, it should be stated that it was performed by the 
late Dr. Hayward. That anaesthesia was employed at all on that occasion 

' Such patients are familiarly knowu to our hcspital attendants as ''bad 
etherizers." Some of them are iiiebriates. If they return for a second opera- 
tion, they seldom fail to exhibit the same symptoms as before. 



1870.] A History of tlic Discovery of Modern AiifBsthesia. 170 

Alice Molian has to thank me ; althongli, if annesthesia had not been 
employed in this particular instance, the test of ampntation would have 
been delayed only till another sliould occur. The circumstances may 
illustrate the sort of obstacles Morton encountered. The loolced-for 
opportunity had arrived; hut, throii^h various antagonistic influences, 
Morton, in spite of his earnest request, had l>een notified tiiat ether 
would not Ijc administered, and tl\at he need not attend the operation. 
Of this he informed me the night before, and by arrangement with him 
I carried him to the hospital the next day, just before the operation, there 
to await events. A dose of laudanum had been administered, and Alice 
Mohan wiis carried to the amphitheatre, for operation without ether. I 
there strongly urged the employment of the yet ostensil)ly secret agent; 
partly on the ground that it then was really known, but especially from 
the consideration that humanity ought to supersede any doubts connected 
with professional etiquette. This and other considerations prevailed, and, 
after a delay of half an hour, Morton, whose presence had been till then 
unknown except by me, was brought up, and the patient was etherized. 

The evidence of all this slowly accumulating antesthetic snrgery, at 
which Dr. Jackson was not present, was claimed for him in virtue of the 
" nurse" argument. What light could a repetition of the chlorine experi- 
ment of Pereira throw upon the question whether a patient could sleep 
during an ampntation ? 

Ether exhilaration was familiar; but, on tlie other hand, it was well 
understood that ether stupefaction was in certain cases dangerous. 
Physiologists had also found tliat the smaller animals very frequently 
died of it. Brodie wrote of the fresh discovery: "I have heard of 
this before, and had tried it on guinea-pigs, whom it first set asleep and 
then killed. The great question is. Is it safe?" This was, indeed, the 
question. Could danger be avoided? what was its exact character? and 
what were its indications? 

On the second of January, nearly three months after the discovery, 
Jackson came to the hospital for the first time. To that date, he had 
been present at one operation only, that at the Bromfield House, 
November 21. He was not cognizant of current experiment, and brought 
voluntarily a bag of oxygen, which he urged upon the hospital surgeons 
as a necessary precaution against danger, erroneously supposed by him, 
at that late date, to be as|)hyxia, instead of over-inebriation, of which the 
essential indication is the pulse. It was some weeks after the discovery, 
that this source of danger, and its sign, were understood; and in the 
mean time Morton might have killed anybody. A ]iiitient was, in fact, in 
great danger from over-inebriation at the first |)rivate operation. He was 
inhaling, in the continuous wny that was at first supposed to be essential 
to protracted insensibility, through a glass globe of ether, and long after 
insensibility was manifested. The operation was far from completed, 
when a bystander happened to feel the pulse. There was no special 
reason for doubt, inasmuch as the patient was, in general appearance, like 
all former thoroughly etherized patients. The pulse proved to be barely 
perceptible, and the patient to be etherized almost beyond recovery. The 
bystander, after rei)eated observation of other cases, published the fact, 
then first observed, that in ether anesthesia the pulse stood as a beacon 
between safety and danger, between harmless inebriation and fatal nar- 
cotism. This was the discovery that ether was not dangerous; because 
this showed that its danger gives warning, and is under control. The 



180 A Century of American Medicine. [Jan. 

operator was Dr. Dix, the bystander myself, and the discoverer Morton. 
To his impetuous, unremitting, reckless experimentation to establish 
anaesthesia, surgeon, bystander, patient, ether, and apparatus, were all 
for the time, and in that relation, subordinated. Morton had asked me 
to be present, because I was more familiar with the new process than 
anybody except himself, and for the purjiose of aiding him, in emergency, 
with professional advice. But the anaesthesia was his. I assumed no 
responsibility. Had the patient died in a "stupor," as he might well 
have done, Morton was liable ; and as the patient did not die, his was 
the credit. This was real danger. But there was other danger, more 
startling, though only apparent; such as prostration, "trance," or 
"mania," lasting for hours, and for which Morton was in one instance 
threatened with prosecution. What was Dr. Jackson's responsibility ? 
None whatever. He was then absent from the State. What had 
Pereira's chlorine experiment taught him about all this danger ? Abso- 
lutely nothing ; nor could it do so. And he could impart nothing. 

In view of these facts, which leave Jackson standing upon the naked 
experiment of Pereira, we may fairly pause, and ask. What, in the fullest 
sense, were the exact significance and value of the suggestion made by 
Jackson to Morton ? 

Caleb Eddy says, in his sworn testimony, "I said to Dr. Jackson, 'Dr. 
Jackson, did you know, at such time, that, after a person had inhaled the 
ether and was asleep, his flesh could be cut with a knife without his 
experiencing any pain?' He replied, ''So, nor Morton either: he is a 
reckless man for using it as he has.' " 

Waiving this testimony, it is clear that the whole of the peculiar know- 
ledge embraced in t!ie suggestion of Jackson to Morton would have been 
accurately and fully conveyed in the two words, "Try ether." This sug- 
gestion should be fully credited to Jackson. Morton never questioned 
the fact of the suggestion ; on the contrary, he at once proceeded to 
square the account. Jackson at first distinctly agreed to receive five 
hundred dollars, as full compensation for the assistance he had rendered. 
As the evidence grew, and the greatness of the discovery became more 
apparent, Jackson raised his demand to ten per cent, on the sales of 
patent rights. Later, when it was clear that the lottery ticket had drawn 
an immense prize, Jackson again increased his demand to twenty-five per 
cent., which Morton refused. Tiie controversy was then opened. 

I very early urged the inexpediency of a patent, if only on the ground 
that, like Whitney's cotton gin, for example, this invention was so valuable 
that the world would combine, as the event has shown, to take possession 
of it; and that the question of equivalent might safely be left to public 
generosity, which has generally recognized such debts. Ether antethesia 
was at first opposed on the ground of its danger, of quackery, of religion, 
and of professional etiquette. Much of the early opposition to a patent^ 

1 The first statement of the fact of operations under insensibility was a paper in 
the Boston Medical and Sur/^cal Journal. Nov. IS, 1546, eutitled "Insensibility 
during Surgical Operations, produced by Inhalatiou. Read before the Boston 
Society for Medical Improvement, Nov. 9, lS4(i, an Abstract having been previ- 
ously read before the .American Academy of Arts and Sciences, Nov. 3. 1S4(), by 
Henry Jacob Bigelow, M.D., one of the Surgeons of the Massachusetts General 
Hospital." A copy of this was sent by a gentleman to bis friend. Dr. Boot, of 
London, and by him transmitted to several London surgeons. Their replies to 
Dr. Boot I have in my po.ssession. This paper also announced the patent, and 
the connection with it of the names of Morton and Jackson. 



1876.] A History of the Discovery of Modern Anaesthesia. ISl 

came from dentists, who desired to use tlie new method without pay; and 
they confused with it the question of luimanity to suffering. But in those 
days dentists had secret methods to whicli tliey attached a money value, 
and which went fur to justify both secrecy and patent. The question of 
secrecy sliould, however, be detached from that of equivalent. Dentists 
and ]»hysicians, lawyers and clerirymen, dealers in food, heat, lisrht, labour- 
savinu; methods, in short, in comfort, knowledge, and vuhiff, riglitly exact 
a pecuniary equivalent, proportioned to their services, from tliose who 
can pay it without inconvenience. The more distinctly this is recognized, 
the l)etter we shall understand the nature of real humanity, and the more 
readily lend assistance and charity to those who need them. Jackson was 
right in expecting a money return for the service he had rendered. The 
only question here is. How much he himself, at first, considered a fair 
equivalent for this service. This has been shown. 

After it became evident that the patent was worthless, Jackson repu- 
diated the division, and claimed the whole discovery, in virtue of the 
"nurse" argument. Under these circumstances Morton properly insisted 
that the " suggestion" could have been picked up from almost any source, 
by any man actively searching for painless dentistry, who knew everything 
about Wells's experiments with gas, and who also knew the familiar 
and similar action of gas and ether. Morton was right. 

But Morton also urged that this was a discovery not in science, but in 
art ; that surgical anesthesia was due, not to any great scientific novelty 
in the long recognized ether insensibility, but to his having worked oat 
the application of this insensil)ility to use in. art, with enterprise and per- 
severance, through many details, in the midst of danger, till he gave to 
the world a perfected system of efficient and safe anresthesia. Morton 
was again right. 

When a discovery is great, not from the intellect invested in it, but 
because it ameliorates the condition of mankind, then its recognition has 
more of a business character, and the gratitude and honour bestowed by 
the world are more nearly an equivalent for value received. The world 
does not concede the equivalent until it has received the value ; and it is 
apt to examine with business exactness the claims of those who profess 
to have acted as agents in the matter. 

This suspicion of discoverers who do not appear until after the world 
has been made to recognize the discovery is justified by the fact that 
hardly an invention of importance was ever made known that it was not 
at once claimed, often simultaneously, from a variety of sources. This 
is not remarkable. The world, whether in science or in art, is built up 
to a certain point by the easy and wide transmission of knowledge. 
Upon this elevation stands a multitude of philosophers, engaged often in 
identical researches, and possessed of much information upon the subject 
in question. Each of these may honestly believe that his imperfect 
knowledge is the perfected knowledge in question. In such a case the 
world is liable for a short time to confound claims, to confuse the incom- 
plete result of a few data with the completed demonstration from many, 
the unproved with the indisputable, theory with fact. Recognize this 
fallacy, and the question of invention is comparatively simple. Yet it is 
not recognized. There is at this day the same claim to priority in in- 
vention as existed half a century ago. The writer of a Life of Fulton 
then said : " Those who question Mr. Fulton's claim are precisely those 
who have been unsuccessiul in their own attempts ; and it would seem 



182 A Century of American Medicine. [Jan. 

that exactly in proportion as their eiTorts were abortive, and as they had 
thrown away money in fruitless experiments, their claims rose in their own 
estimation and that of their partisans." The witness — T believe before 
the House Commons — probably did not overstate the matter when he 
gave it as his opinion, that, if a man were to show that he l)ad found a 
road to the moon, his neighbours would testify, that, if they had not 
been there tbeiinselves, they knew several persons who were familiar with 
the road in question. It is hardly too niuch to say, that, at the ])resent 
day, every invention or discovery having a large supposed value is sys- 
tematically contested. 

Morton, in his attitude of investigator, had a right to receive a bint or 
suggestion of greater solidity than tliat of Jackson, without impairing 
his merit as inventor. Every invention is preceded by such hints or 
suggestions derived from experiment, books, or people. Curtis (on 
Patents) says: " It is clear that many suggestions may have been made, 
or many hints taken from others, without invalidating the claim of a party 
to l)e considered as the author of the invention." 

Of a hundred instances easily cited to illustrate this, let us confine 
ourselves to a medical one, that of the invention of vaccination to avert 
smallpox. 

The young countrywoman of Sodbury said of smallpox : " I cannot 
take that disease, for I have had cowpox." The Duchess of Cleveland, 
when Lady Mary Davis and other companions taunted her as likely to 
deplore the loss-of that beauty which was her boast, as the smallpox was 
then raging in London, said that she had no fear about her beauty, for 
she had had a disorder which would prevent her from ever catching the 
smallpox. Were these discoverers ? Surely, yes, if Dr. Jackson was one. 
In fact, the hint that they and others gave to Jenner in the vale of 
Gloucestershire, where he resided, embodied more knowledge of vaccina- 
tion than Dr. Jackson's suggestions did of ether anaesthesia.^ But 
neither the milkmaid nor the Duchess of Cleveland was ever honoured 
as a discoverer of truth, or an inventor of method, while Jenner was 
so lionoured. The reason is obvious. They, like Dr. Jackson, asserted 
a doubtful fact, and had neither time nor inclination to jjursue the sub- 
ject ; but Jenner, by multiplying instances of the cowpox inoculated like 
smallpox, which was already supposed to be, like smallpox inoculation, 
protective, conclusively proved that it was thus protective, and also safe. 
He did with cowpox what Morton did with ether. 

The parallel in this case is very close. Jenner and Morton were in 
pursuit of what the scientific world regarded as a chimera. Because they 
believed in its possibility they encountered prejudice and opposition. 
They both received from others a hint, suggestion, or snnnise, which 
afterwards proved to be capable of development into a truth of great 
value. This suggestion was based on narrow induction, and luid, there- 
fore, obtained no previous general credence. It had also sluml)ered for 
years at that stage of fts development. The world had not believed it. 

Jenner and Morton, both men of singular persistence and perseverance, 
took hold of this idea, of which, from the nature of their daily pursuits, 

' The experiences of the milkmaid aud the Duchess might easily have apprised 
theiu of their own imrauuitj from smallpox. But .Jackson, through his chlorine 
expHi-iiiients, could have no evidence that ether stupor was capable of alL-cting 
all persons, or that it <:ave immunity from real surgical pain, or was free from 
danger. iS'o self-experiment could touch these points. 



1876.] A History of the Discovery of Modern Anaesthesia. 183 

they ft'It the immense viihie. But for them it mif^ht hiive slumbered in- 
defiiiitt'Iy. Tliey drafrfjod it throiiijli till the world recognized it and thera. 
Tliis they did at the risk of iiijiirintr people's health, of killing them, and 
of beitifc held resjionsible for so doiiip;. Nol)ody has ever doubted that 
Jeniier was the inventor of vaccination, and nobody should doubt that 
Morton was the inventor of modern amesthesia. Here the parallel ceases. 
The English people voted Jenner a reward of 8150,000.^ 

The world demands convincing demonstration — ami not by an individual 
for himself or to himself, but to them and for them, with overwhelming 
cleurness. Then, and not till then, it responds with acknowledgment, 
concession, or gratitude. 

Sydney Smith, in the Edinburgh Review, insists on this. In fact, he 
wittily overstates the claim of the mere pul)lisher of a novelty, when he 
says that "he is not the inventor who (irst says the thing, l)nt he who 
says it so long, loud, and clearly, that he compels mankind to hear him."^ 

' In decisions relating: to discovery, unanimity is not to be expected. There 
can l)e none where partisanship aii'i large interests are involved. The qnestion, 
tlien, is, Wliere the weight of evidence lies. Even Jenner, with no rival, eucoun- 
tert>d great liostility both to himself and his discovery. The House of Commons 
(June -, 1802) voted him ten thousand pounds by a vote of ■'>'.* to 5 ', a majority 
of three only. A further sum of twenty thousand pounds was voted (June 29, 
1807) by a vote of liO to 47, a majority of thirteen. Morton's award of $IO(t.OOO, 
for his patent, passed the Congressional Committee. It was arrested, not wholly 
by Jackson, but by the partisans of Horace Wells, who published what afterwards 
filled an octavo volume, containing little argument, but full of bitter invective 
against Moiton, and promised, if only delay were granted, to make a conclusive 
case for Wells. 

2 It is easy tounderstand whatis meant here. For instance : I have amputated 
more legs after applying a tight bandage from foot to hip before tightening the 
tourniquet, than in any other way. Similarly to the arm for a needle in the hand. 
A hundred surgeons have done the same thing 8ir Charles Bell went a step fur- 
ther, and announced the dry method in print. " I may here observe," he says, 
"that by the management of the tourniquet, blood may be lost or gained. If the 
limb be uniformly rolled before amputation, the veins are emptied into the general 
system, and blood is saved instead of being withdrawn. In a very exhausted state 
of the patient, it may be of service to attend to this." (Great Operations of Sur- 
fferi/, Loudon, '1S2I, p. AS.) But Hsmarch was so impressed with its importance, 
that lie erected it into a s^'stem, and urged it upon the attention of every siirgeon 
in the civilized world. To many the idea was new. In fact, to a considerable part 
of the surgical world Esvnarch was the discoverer of an important truth. He 
deserves to be avowed as such, in requital of his pains to perfect and to publish 
to the surgical woild. a useful point, new to many of them. He is so recognized. 

Antiseptic precautions in surgery are not new ; but Lister published his views, 
as did Esmarch. Whether germs are essential to the theory or not, there can be 
little doubt that it is well to free a wound from coagula. and to wash it out with 
diluted carbolic acid or its equivalent. Then the subsequent free use of the anti- 
septic, by hindering decomposition without, tends to maintain vitality within the 
wound. These views have been enforced and brought home to the world by Lister, 
with the pertinacity of Jenner or of Morton. The world at large owes its attention 
to these points to Lister's announcements, and properly attaches his name to the 
antiseptic method. 

Mere publicity is notoriety; but with merit it is fame ; with originality it is 
discovery. To all these publicity is essential. He who keeps his discovery com- 
paratively to himself discovers, or uncovers, nothing. If he claims to have done 
so, the world will scrutinize and suspect his claim. 

The act of publication, indeed, adds little to the claim of Morton ; his impregna- 
ble position being that he elaborated and jjerfected a new art. But facts like the 
above go far to show that the failure of Jackson for four years to publish his alleged 
guess, of itself extinguishes any claim to its recognition during that time. 



184 A Century of American Medicine. [Jan. 

Thus put, however, the statement throws li.u:ht on Jackson's prominence 
after the discovery. An unproved liypothesis in physioloj^y, which was 
his whole claim, would usually be considered of little account. But Jack- 
son knew the machinery of fame. As Wells by accident, so Jackson 
by his scientific relations, and through his friend and former teacher, 
Elie de Beaumont, got at once possession of the scientific rost-rum of the 
French Academy of Sciences and other foreign learned societies. He 
also subsequently addressed Humboldt. He thus compelled the European 
world, even so far as Turkey, to listen to his exclusive statement that the 
whole was his. In the mean time, however, there was in Boston a 
scientific jury of the vicinage. When Morton's statement at last crossed 
the water, the French Academy did what it could at that late day, 
and awarded to Morton the same honour and recognition it conferred 
upon Jackson. It could do no less. It could then do no more. But 
had the case been at the outset reversed, and had Morton made a sugges- 
tion to Jackson, does anybody doubt that the humbler Morton, and his 
suggestion, would have been by scientific precedent wholly absorbed and 
assimilated ? 

All honour, then, to the inventor of the art of antesthesia! — for there was 
little science in it. He found the practice of ether inhalation an amuse- 
ment of chemical lecture-rooms and schools ; he left it the sovereign 
anodyne of the human race in its moments and hours of agony. He 
found ether stupor as hazardously uncertain as vvas the narcotii^m produced 
by pouring down the opium " cl hoire^' of Canappe ; he left it as man- 
ageable and safe as the sleep that follows a dose of laudanum. 

There is hardly an inhabitant of the civilized world but can remember 
some one of those nearest to him in whose experience the anguish of the 
knife or of disease, of birth or of death, has been assuaged by anaesthesia, 
perhaps converted into a pleasant dream. Yet he is willing to take this 
priceless boon as a gratuity from those whose sole patrimony it was, and 
who have been brought nigh to want that he might enjoy it. If the 
world should cancel a fraction of its debt, the family of the inventor could 
afford to be generous to the families of his former friends, who, without 
impairing his title to the discovery, contributed to his success. 

Wells's sad story has been told. Morton fell with apoplexy, induced 
by a publication in behalf of Jackson, of a nature to prejudice a subscrip- 
tion then arranged in New York for his benefit. Jackson, it is to be 
feared, is at the present time hopelessly bereft of reason. 



I87fi.l 185 



REVIEWS. 



Art. XVIII —Works of B. A. Morel. 

1 . Ef Idles cliniques sur les AFaladies 3Ienfales, 2 vol. 8vo., avec planches 

1851-52. 

2. Traite des Degenerescences physiques, intellectuelles et morales 

de VEsp^ce humaine et des causes qui produisent ces varieles 
maladies, avec \m atlas de 12 planches, etc., pp. 700. 1857. 

3. Traite des Maladies mentales, 1 vol. grand 8vo. pp. 866, 1860. 

4. Traite dela Medecine legale des alienes, 1 vol. 8vo. pp. 160, 1866. 

Probably no other person of our time, engaged in the study of mental 
obliquities, has disphiyed more patient industry, more comprehensive in- 
vestigation, greater freedom from narrowness and )>rejudii'e, a more philo- 
sophical spirit of inquiry, than the author of the works whose titles are 
here given, and yet we doubt if these works are much known out of his 
own country, and even there they do not seem to have left very deep traces 
of their influence on the literature of this department of medical science. 
It is the frequent fate of new truths and happy conceptions to meet with 
tardier recognition than the lesson of a brilliant experiment, or some 
striking application of an old truth. Their bearings may not be so readily 
apprehended ; they may conflict with other truths, apparently, or offend 
some cherished oi)inions ; their speedy reception would require some self- 
abnegation, some acknowledgment of error, and this is distasteful to most 
men. Like tlie man in the play, who, when urged to save his wife from 
drowning, said he would go iionie and think about it, they are ever in- 
clined to prolong the struggle between their fealty to truth and that happy 
conservatism that hates to be bothered with the claims of progress and 
improvement. If they only would think al)0ut it ! But they are too 
often glad of any excuse for dismissing it from their thoughts altogether. 

The recent demise of Dr. Morel furnishes a fit occasion for presenting 
to our readers some account of his labours as recorded in the works before 
us. Considering the many and bulky volumes they make, the longest 
article our space could afford must necessarily be brief, but what we say 
may, at least, lead the reader to a better acquaintance with their con- 
tents. 

Shortly after his graduation in 1839, Morel became acquainted with the 
elder Falret, whom he assisted in his labours and from whom he imbibed 
that interest in mental diseases which thenceforth made them the sole 
study of his life. In 1848 he was appointed to the charge of the hosjiital 
for the insane at Mareville, and subsequently to the charge of that at 
Rouen. In the former institution he gave clinical lectures to medical 
students, which were published in 1852. In this shape they consist of 
brief descriptions of the various forms of insanity, illustrated by full and 
graphic accounts of particular cases, constituting a work remarkably sug- 
gestive and interesting. A nice appreciation of mental obliquities, an un- 
rivalled accuracy of observation, and an unusual felicity of expression, are 



186 Reviews. [Jan. 

apparent on every page. With none of the method and formality of most 
text-books, it none the less impressed upon the student's attention the 
salient points of the subject, and especially the relations between the differ- 
ent manifestations of disease Combining the philosophical spirit of Pinel 
with the practical sagacity of Esquirol, the facts of mental pathology, 
under his teaching, were invested with new significance, and the revela- 
tions of the cliniqae were made to throw a flood of light on many a dark 
passage in the history of mental disease. That a work of such abundant 
merit should have been so rapidly prepared, indicates talents remarkably 
adapted to his chosen field of labour, and a mental discipline that made all 
things easy. It is great praise to say of any book, as we do say of these 
Etudes cliniques, that its value and freshness will never be impaired by the 
progress of knowledge, and that it will be read as long as the study of 
mental pathology shall be pursued. 

After this, Morel's attention, following an early bent, was concentrated 
upon those changes in the human organism which may be rightfully 
regarded as degenerations. His doctrine briefly stated is, that under ex- 
posure to various adverse agencies contained in the soil, climate, food, 
or to sensual indulgences, the organism suffers a deterioration which, by 
accumulation through successive generations, finally ends in complete 
extinctiou. At first l^liish, this statement calls to mind, in nineteen per- 
sons out of twenty, that horrid affection prevalent in certain parts of 
Europe and America, under the name of cretinism, and they will, pro- 
bably, hesitate long before fixing upon another example. Not so Dr. 
Morel. He finds fruitful sources of degeneracy in the use of alcoholic 
drinks, opium, and tobacco, in exposure to certain mineral substances 
employed in the arts and manufactures, such as lead, mercury, phosphorus ; 
in the use of cereals bearing poisonous parasites, especially the ergot of 
rye and maize; in a scanty nourishment; bad sewerage, and filthy habita- 
tions. 

Before considering with our author the operation of the.se malign agen- 
cies, it may be well to understand exactly what he means by degeneration. 

We .see on the face of the earth various races of men greatly differing 
from one another in those qualities which are associated witli all our 
ideas of human excellence. They differ in stature, in complexion, in the 
shape of particular members, in size and strength, in intelligence and the 
means of comfort. How strong the contrast between the Caucasian with 
his lofty brow and commanding figure, and the Negrillo of Australasia, 
with his dwarfish frame, and orang face; between the tall, strong, finely 
formed Caffre of Southern Africa, and his diminutive, puny, feeble neigh- 
bour the Bosjesman ; between those lithe, agile, and restless races that 
roam over our Western wilds, and the squat, dull, and shapeless native 
of the Hyperborean shores. How are these diversities to be explained ? 
If men have sprung from different original creations, they may be supposed 
to be now precisely what they were in the beginning — sunie of them having 
varied slightly from the original type under the operation of obvious 
agencies —and wisely adapted, like other animals, to the physical conditions 
in which they were placed. Of course, this indicates no degeneration, but 
admiraljle adaptation. But our author clings to the unity of the race, and 
to avoid the necessary conclusion that some of these diversities look very 
much like degeneration (for he does not, for a moment, imagine that the 
primitive man was a Negrillo, and consequently, every other race an im- 
provement on that), he sets up his definition of degeneration, which is, he 



ISTT).] Works of IJ. A. Morel. 18T 

says, "a deviation, iiuluced by inorljid action or lesion, from tlie primitive or 
normal type of humanity." So loiij; as a race or community continues to 
propagate and multiply, no dejjree of det^radation must l)e altril)uted to 
defeneration, l)ut, rather, to physical conditions wliicii, however unfavour- 
able to the development of the best qualities of humanity, produce no 
morbid processes. The position is not a very strong one. The marvellous 
power attributed to climate and other external circumstances is purely 
speculative, for no such effect has come within the range of human obser- 
vation, which embraces a very large portion of man's existence on the 
earth, according to the popular system of chronology. If the 'morbid 
element is essential to our author's idea of degeneration, his consistency 
would be l)etter preserved by resorting to the doctrine of several creations 
of the hunu\n races. 

Of all existing forms of degeneration, cretinism is the most known, the 
most prominent, the most repulsive, involving more than any other the 
issues of life and death. It furnishes a standard of degeneration ))y which 
all others are graded and measured. Springing from telluric condition-?, 
not yet very well understood, it becomes endemic, affecting a large i)ropor- 
tion of the population, passing from one generation to another by force 
of heredity, and in its severest grades so vitiating the springs of life as to 
produce utter sterility, and so cures itself by complete extinction. 

Of all the causes of degeneracy now in action, none can compare with 
that of alcoholic liquors, in the aggregate amount of mischief jiroduced. 
TJnconfined like cretinism to a few small districts, it pervades all Christen- 
dom; it spares neither sex nor age nor social condition; it is swift and in- 
tensely damaging in its operation. Considering these points in its history, 
we can scarcely exaggerate the magnitude of the evil produced by alcohi^lic 
drinks. The efforts of the legislator, the sanitarian, and the moralist have 
failed even to check its [)rogress. It is so widespread, it makes itself felt 
in so many ways, clearly and ob.scurely, in the present and in the future, 
on the surface and in the deepest recesses of organic life, that it defies the 
utmost power of statistics to measure its effects. Sweden, by all accounts, 
is pre-eminent for indulgence in intoxicating drinks, and in one particular, 
certainly, the legitimate effect is obvious enough. Statistics collected a few 
years since show that in the districts where the consumption of such 
drinks was greatest, the mortality was about double that of districts where 
the consumption was least. The destructive effects of habitual drunkenness 
on tlie various organs is known to every one, l)ut the extent to which the 
nervous system, and especially the brain, is affected, is not so well under- 
stood. True, delirium tremens is known to all men as one of its most 
shocking results, and general paralysis or paresis is found in every insane 
hospital in the land, yet few are aware how far its evils are spread beyond 
the individual immediately concerned. In this, its hereditary character, 
consists its power for effecting the degeneration of the race. No fact in 
medical science is better established than that it vitiates the quality of the 
brain, and recent observations have abundantly shown that this vitiation 
is often transmitted in one shape or another to successive generations. It 
may be a repetition of the ancestral vice, but it is about as likely to be 
idiocy, or imbecility, or insanity, or epilepsy, or criminal propensities. A 
single leaf from this frightful chapter of heredity, presented by Morel, tells 
in a Cew words the story that might also be drawn from the observations 
of others who have had charge of hospitals for the insane. A man from 
the district of the Yosges, where drunkenness is pre-eminently prevalent 



188 Reviews. [Jan. 

got killed in a drunken quarrel. His son was a drunkard, who became 
insane and died of general paral3'sis. His son was sober, l)ut became 
hypochondriacal, then insane, and a life-long inmate of a hospital. His 
son was born feeble-minded, became insane at the age of sixteen, and 
passed into a state of dementia. Such was the progress of the cerebral 
vitiation through four successive generations. The records of hospitals 
for idiots show that a large proportion of their subjects have sprung from 
a drunken ancestry. And thus is manifested the last distinctive feature 
of degeneration as defined by our author — sterility and extinction of the 
race. 

The deleterious effect on the constitution, of intermittent fevers, the 
product of malaria, is obvious enough in the person immediately affected, 
but in his descendants it is greatly weakened by salutary changes in the 
condition of the soil, and in some measure by the process of acclimatization. 
In the marshy districts of France, however, the mischief is profound and con- 
tinuous. The people of La Bresse, Ija Sologne, Du Berry, and La Brenne 
are said to present a most striking ideal of extreme human degeneration. 
They begin from the cradle to be prematurely old, feeble, and sickly, and 
are so dwarfish that these districts are often unable to furnish their con- 
tingent to the array. Old age begins at forty or fifty ; they are decrepit 
at fifty-five; and seldom is life prolonged beyond the age of sixty. The 
people of La Bresse, says the writer of the medical history of these marshy 
districts, if they survive beyond the seventh year, are dropsical, with a 
sallow skin, tumid features, and rickety bones. They are subject to fevers, 
putrid and malignant, to passive hemorrhages, and incurable ulcers. 
They do not live, they vegetate, or rather, they die. 

In tobacco, hachisch, and opium, Morel finds agencies destructive of 
healthy vigour both of body and mind, though hardly to that extent which 
can be properly called degeneration. If moderately used, they exert no 
very obvious deterioration, and if used excessively, they finish their sub- 
jects speedily, and thus prevent the transmission of much evil. That 
these and other stimulants and narcotics in which men indulge have 
weakened the power of the race, producing an inferior type of humanity, 
is not unlikely, but it must ever be a matter of speculation, not suscep- 
tible of absolute proof. And as to the other more general question 
whether in the course of ages, from these or any other agencies, the hu- 
man creature has improved or deteriorated, the world is far from even 
an approach to unanimity of opinion. On the supposition that all the 
various races have sprung from a common stock, then, of course, there 
has been immense progress, in one direction or the other. It must have 
happened, however, in periods far beyond the reach of history, for it may 
be considered as a settled conclusion that only the most insignificant 
changes in the animal form or structure of man, have ever come under 
ob.^ervatiou. Even giving the question a narrower sweep, and cou fining 
it to one particular race, the Caucasian for instance, still the answer can 
be scarcely more certain. During the six or seven thousand years of 
which we are supposed to have some record, we have no evidence that it 
has deviated from its original type. Indeed we have much positive reason 
to believe that it has preserved its characters as steadily as the inferior 
animals have theirs. It will hardly be contended that at the present day 
the genus Homo is any better represented than it was by Alcibiades and 
Pericles in their day. We would not deny that the race is endowed with 
an inherent power of improvement, but it has been chiefly manifested in 



1876 ] Works of B. A. Morel. 189 

the structure nn(i functions of tlie nervous system. "While we may fairly 
doul)t whether, in physical beauty and viffour, in power of endurance, in 
freedom from disease, and in lentrth of life, there has been any gain during 
the periods embraced by historical recorls, we are obliged to admit that 
there has been au improvement in that part of his structure on which the 
highest and noblest qualities of the animal depend. By virtue of its own 
inherent powers, the Caucasian brain evinces a tendency to improvement, 
that is, to enhance the quality of its structure and tlierel)y to enlarge the 
sweep of its action. Why this character of the cerebral system has not 
etfected a higher grade of excellence in the race as a race, as the laws of 
physiology might have .led us to exjject, will be readily understood on a 
little reflection. It must be remembered that organic changes either for 
better or for wor.^e, cannot become fixed, estal)li,slied traits in the subsequent 
generations, without an exact compliance with the laws of breeding. To 
render any organic trait permanent, it is required that only those indi- 
viduals should cohabit in whom it exists, and this for several generations. 
Disregard of this rule is sure to be followed by the utter disappearance of 
the desirable trait. That this rule has never been observed by men and 
women in their unions, is a fact too well known to require any special 
proof. And even now, with all the advantages and inducements of our 
superior knowledge, we see men who would not think of buying a horse 
or a cow without consulting the herd book, and becoming perfectly satis- 
fied in the matter of healtli and blood, taking, for life-long partners, to 
become the mothers of their offspring, women who eml)ody the infirmities 
of previous generations, and have nothing to contribute to the improve- 
ment of the stock. And thus it happens that whatever gain may have 
been made in one generation is lost in the next, and the race remains at 
its old level. And so it must ever be as long as the world ignores that 
stern physiological law, that no desirable trait, feature, or quality can 
become permanent in the race, until it has passed along through several 
successive generations, and thus become, as it were, firmly incor[)orated in 
the constitution. 

The J'?'a^7e des Degenerescevces, without having added much to our stock 
of knowledge, is an important contribution to physiological science, by 
calling attention to certain vital processes not sufficiently considered at 
the present time, though intimately affecting the welfare of the race. It 
lacks scientific method and precision, and facts are treated with too little 
regard to their relative importance. The distinction between degeneration 
and deterioration is not always observed, and thus the reader is subjected 
to some confusion of ideas. A large part of it is devoted to agencies 
which, however destructive they may be, are not shown to be causes of 
degeneration as defined by the author himself. In the matter of proof 
science is inexorable, and will not be satisfied with surmises or plausible 
deductions. Nobody will deny that spirits and tobacco have impaired 
the stamina of the race. All will admit that if it had always lived in a 
state of Arcadian simplicity, the tables of mortality would now tell a very 
different story. To the use of these noxious agents, we are accustomed 
to attribute in our crude generalization, much of the disease, feebleness, 
insanity, mortality and crime that afflict every civilized community ; but 
strong as our conviction is, who will undertake to measure and define the 
several particulars in the aggregate amount of all this mischief, and also 
separate it exactly from the effect of all those other noxious agencies that 
have done their part in eufeebliug and depraving the human constitution ? 



190 Reviews. [Jan. 

Undoubtedly tlie evil in question, reinforced by the casual concurrence of 
other evils resulting from adverse circumstances, may end in the last stage 
of degeneration — sterility, and extinction — but it may be fairly doubted 
whether that result has ever happened as the direct and legitimate product 
of the use or abuse of spirits and tobacco, however much it may have 
accumulated in its passage through many generations. 

Morel's next considerable work is the Traite des Maladies Meufales, a 
ponderous octavo, equivalent to three or four of the more common size 
and type. Much of it might have been left out without impairing its 
value. Like the work just noticed, it abounds in I'epetitions and irrele- 
vant details, and the style is pervaded by obscurities of expression that 
try the patience of the reader. Still, it is a better specimen of book- 
making than the other, and will be read and prized by the medical scholar 
as long as any work which the present generation has contributed to this 
department of knowledge. It has all the claim to originality which con- 
sists in viewing old facts in a new light and giving them an interpretation 
different from any they have received before. Not one of the least of its 
merits is that it is eminently suggestive of thought to others, and the reader 
rises from its pages deeply impressed with the conviction that he has been 
in the company of a wise, careful, painstaking observer. 

The present work is the legitimate outcome of the former. Hereditary 
insanity our author regards not as a simple derangement or lesion of 
structure produced by accidental and temporary causes, but as a veritable 
degeneration, and that, even when a primitive, independent fact in the 
individual, it is liable, after many transmissions, to become a degeneration 
ending in extinction. He regards the disease as being properly hereditary, 
not only when it has been preceded in a previous generation by overt 
insanity, but also when the ancestral trouble was some other and perhaps 
minor nervous affection — epilepsy, chorea, hysteria, somnambulism, neu- 
ralgias of the head. This view is amply supported by the observation of 
others, and has become, we believe, the prevalent opinion. We are not 
ready, however, to allow Dr. Morel's claim to its paternity. He may 
claim, perhaps, priority of publication, but we cannot forget that the doc- 
trine was developed by Moreau de Tours, in \us Psychol ogie ^Lorbide printed 
in 1859, with a fulness of illustration drawn from the records of history, 
of clinical observation, and the laws of physiology, sufficient to carry con- 
viction to the most unwilling mind. It is not strange that two such men, 
with their training and surroundings, should have evolved from their 
studies a great truth that was the last step in the course which the 
inquiries of the time had taken. He thinks insanity has been too much 
considered from the side of its symptoms, or outward manifestations, to 
the neglect of the inward lesion. This he believes to be always essen- 
tially the same, differing in its characters in different individuals with the 
incidents which havj led to its production. It is not a new discovery, 
certainly. Insanity produced by syphilis, chiefly as the exciting cause, is 
not precisely the same thing as insanity produced l)y a blow on the head, 
or a cancerous disease of the womb. 13ut no sufficient account has been 
made, Dr. Morel thinks, of such causes, in considering the progress, 
and especially the treatment of the disease. 

In accordance with these views, he thinks that mental diseases should 
be classified on an etiological basis, and not, as they generally are now, 
on that of symjitoms. Because when called to deal with a mental disease, 
the point with which we are most concerned is, not how it manifests itself 



1876.] Works of B. A. Morel. 191 

to the world, l)ut what is the character of the orpjanic change, and wliat 
caused it The more we have of these facts, the nearer we ap|)roach a 
successful therapeutics. Accordingly, he nialces of mental diseases, six 
general classes, each embracing several subdivisions, viz., those having an 
hereditary origin ; those produced l)y into.xication ; those produced l)y 
hysteria, epilepsy, and hypochondria ; those produced synipatlieticaily l)y 
other diseases; those which have an idiopathic origin ; those which con- 
stitute the natural terminations of all mental disease. Some sort of 
ciassilication, no doubt, we must have, but its importance is greatly over- 
rated, and this, as compared with others, is not calculated to raise the 
estimate. The oltject of all classification is to bring those things together 
that have certain i)oints of resemlilance ; and as it regards living things, 
it is supposed to advance our knowledge of them according as it is founded 
on the most constant and essential elements of their structure, rather than 
on those which, however obvious and striking, are not necessarily connected 
with the inmost, specific character of the creature. This princi[)le, we 
presume. Dr. Morel had in view in classifying, as he has, the different 
forms of insanity, and it has the show of being very exact and philosophi- 
cal. The first question, however, which the student will ask, will be whether 
the forms of disease thus brought together have that kind of resemblance 
we naturally expect in a system of classification — a resemblance that 
embraces not one trait or incident alone, but the general aspect. Dr. 
Morel thinks they have, and he may have a gift of discernment large enough 
to enable him to see it, but we doubt if his opinion is shared by many. 
Perhaps no form of insanity is better marked by uniformity of manifesta- 
tions than the epileptic; and yet how many cases, without the fits, we 
should fail to recognize, guided by this means alone. Then, too, by what 
characters are we warranted, for instance, in saying that this or that case is 
hereditary? We do not hesitate to say that there is no form of mental dis- 
ease whatever in which heredity may not have been the most potent agency 
in its production. Indeed we have seen that our author claims the merit of 
first announcing the truth that the hereditary vice, in its downward trans- 
mission, may assume a great variety of forms. Surely, he cannot have 
failed to observe that in cases that seemed most obviously to spring from 
dyspepsia or epilepsy, or fever or any other bodily disease, there is very 
often, if not generally, an hereditary element. 

We are not disposed to think that this classification would help us much 
in the medical treatment of the disease. Who will say that cases having 
a syphilitic origin are ever cured by mercury and the iodides? Or that 
tubercular insanity ever disappears under the diligent use of cod-liver oil or 
the hypophosphites ? Or that we can be any more successful by showing 
that the father or mother of our patient was insane before him?? True, our 
author, as well as others, points with much satisfaction to the speedy 
recovery of female patients under medication directed to the uterus or its 
appendages. We would not dispute the fact, but it would be difficult to 
find another of a similar character. On the contrary, the physician of the 
insane is taught by every day's experience that removal of the supposed 
cause is seldom followed directly by the cure of the disease. 

Two hundred pages are devoted to the causes of insanity. The ordi- 
nary distinction is made between predisposing and exciting or occasional 
causes, and the remarks upon them are signally judicious and instructive. 
It is a favorite doctrine of the author, that while the action of both these 
classes of causes is needed iu the production of the disease, the particular 



192 Reviews. [Jan. 

form it assumes is determined by the nature of the predisposing cause. 
Knowing the latter, we have no difficulty in ascertaining the former, and 
vice versa. A third element is also found in every case, which he desig- 
nates as the functional trouble or lesion, but the part which it plays is 
not very clearly made out. Nor is the general doctrine of the alleged 
relation between the cause and the form of the disease demonstrated by 
fliiiical facts. It only excites surprise that an observer like our author 
should deliberately say that " hereditary insanity has its essential charac- 
ters, and the cases belonging to this variety may be recognized by certain 
signs." Considering that by far the larger part of insanity in the world 
has an hereditary origin, it is impossible to reconcile this fact with the 
uniformity of character which our author attributes to all mental disorder 
coming from that source. On the contrary, it needs no very extensive 
observation to learn that the ancestral defect may manifest itself under 
any of the existing forms of insanity — maniacal excitement, melancholia, 
circular mania, moral insanity, monomania. And the same may be said 
of other agencies in the production of insanity, whether I'egarded as 
predisposing or occasional. If any man can tell us by what outward 
sign we may infer the agency of syphilis, or tubercle, or strong drink, or 
hard study, or a fall on the head, he will make a new contribution to 
our knowledge. With this exception the whole subject is treated in a 
highly philosophical spirit, though with a little of that tendency to 
speculation derived from the author's earlier studies. 

Nearly two hundred pages are given to "general pathology," in which 
the symptoms of insanity common to all its forms are described and 
explained with a very exact appreciation of their significance. We doubt 
if any one, however accomplished in this department, can read it without 
obtaining a valuable addition to his stock of knowledge, but we are obliged 
to pass it by with only a single reference. Nowhere else have we seen 
the idea so strongly set forth that the reasoning, and the association of 
thought in the insane, however widely they may wander, are always in 
accordance with certain laws of mental action. Their utterances, so far 
from being a jumble of incoherent and unmeaning expressions, are, in 
some measure, pertinent to the subject in hand, responsive to questions, 
and follow, it may be, a strictly logical sequence; and the different forms of 
the disease exhibit a characteristic diversity in regard to this trait which 
cannot be too carefully studied, because it furnishes the most reli;ible means 
of detecting simulation. Not being aware of this law, the simulator speaks, 
at one moment, like an excited maniac ; at another, like one with well- 
defined hallucinations or delusions ; and again, like one demented. We 
regret that he did not speak of the simulation sometimes practised by the 
insane. His large clinical experience and familiarity with abnormal men- 
tal conditions would have inspired the strongest confidence in his conclu- 
sions. 

In the section entitled Special Pathology and General Therapeutics, 
are described the various forms of insanity, more in the style and spirit of 
the philosophical student bent on unfolding the beginnings and successive 
stei)S of each mental obliquity, than of the clinical observer concerned only 
with tiie practical management of the cases he is to meet. More than 
any previous writer, as we have already intimated, he has dwelt upon the 
hereditary element and enlarged the scope of its action. In this particular 
his work is especially valuable, because it raises to its proper importance 
an order of facts but barely alluded to by previous writers, though indis- 



187G.] Works of B. A. Morel. 193 

pensahly necessary to a correct understaiidiiig of the nature of insanity. 
It will always be regarded as his peculiar merit that he found in full 
operation, in the evolution of mental ol)liquities, the same laws of heredity 
which Lucas and a few other writers had shown to control the transmission 
of normal traits l)oth mental and bodily. The greater part of this section 
is devoted to the various forms of moral insanity, the description of wiiich 
is illustrated l)y many instructive cases. We liud it hard to conceive how 
any impartial reader accustomed to yield to the force of scientific evidence 
can read and inwardly digest this chapter without admitting that insanity, 
in some of its most deplorable forms, is often unaccompanied by any ap- 
parent derangement of the intellect. He believes, however, that the moral 
monomanias, as they are called — pyromania, kleptomania, dypsomania 
— are not so isolated and independent as at first sight they seem to be, 
but are always the outgrowth of a more radical lesion. 

Our author's medical treatment is not at all of the heroic character. 
He is contented with baths, hot and cold, prolonged and short, and has 
consideral)le faith in the hydropathic use of water. These, with more or 
less isolation or seclusion, are all that are required in the majority of cases. 
In exceptional conditions, he uses opium, tartar emetic, quinia, the bro- 
mides and iodurets. lu his moral management we find nothing especially 
worthy of notice. It contributes to the unanimity with which certain 
principles are acknowledged in every part of Christendom; and nothing 
better could be said in its favour. 

A few years before his death, Morel projected a work on the Medico- 
Legal Relaiions of Insanity, the first part of which only, he lived to 
publish. This was devoted to the doctrines of the ancients resjiecting 
insanity, and especially to those great public manifestations of the disea.se, 
which, appearing at one place or another, at one time or another, in the 
IGth, 11th, and 18th centuries, have not yet ceased to astonish and instruct 
mankind. It is greatly to be regretted that this his last undertaking was 
not completed, for he was peculiarly fitted for it not only by his profound 
knowledge of mental disease generally, but by the particular attention he 
had given to its legal relations. His opinion was sought by judicial- 
functionaries in many an obscure case, and his keen insight into the move- 
ments of the disordered mind rendered his labours in this direction emi- 
nently successful. 

It is not one of the least claims of Morel on the homage of physicians 
and especially of medical jurists, that the flood of new light recently 
thrown on the nature of epilepsy, proceeded, in a great degree, from him. 
He was led to believe — and this belief was so well proved by his own and 
the observations of others who were put upon the track of inquiry, that it 
is now the accepted doctrine amo]ig those best qualified to judge — that epi- 
lepsy, long before it is manifested by convulsion or by obvious nnconscious- 
ness, may become sometimes a potent element of mischief in the actions of 
the patient. In a multitude of cases regarded as those of transitory or 
instantaneous mania, or of some form of moral insanity, he discovered by 
an exhaustive investigation of their history the presence of this disturbing 
force, and thereby solved many a mystery of human delinquency. Pre- 
viously to this our knowledge of epilepsy was confined to the grandma! 
and the petit mal, and some of the more prominent sequels, while the 
pathological condition from which they sprang was regarded as strange, 
solitary, and independent of every other. As to its relations to other dis- 
orders, and especially as to the part which it may bear in the mental 
No. CXLI.—Jan. 1876. 13 



194 Eeviews. [Jan. 

economy before its complete development, these were scarcely a matter of 
inquiry. To Morel and his contemporaries we gladly acknowledge a del)t 
of gratitude for labours highly interesting in their results, not only to the 
pathologist, but to every friend of afflicted humanity. 

Here ends our account of the works of lAlorel, which, imperfect as it is, 
will accomplish its object, if, as is already intimated, it leads the reader to 
make himself better acquainted with their contents. I. R. 



Art. XIX. — Lectures on Syphilis and on soyne forms of Local Disease 
affecting the Organs of Generation. By Henry Lee, Prof, of Surgery 
at the Royal College of Surgeons of England, Surgeon to St. George's 
Hospital, etc. 8vo. pp. 246. Philadelphia : Henry C. Lea, 1875. 

The object of this book, as stated in the preface, is to illustrate some 
of Hunter's views, which the lapse of time and the dissemination of more 
recent doctrines have obscured or caused to be forgotten. In addition to 
Hunter's views, Mr. Lee has also included some of Pearson's with regard 
to the treatment of syphilis, which, in the author's opinion, deserve more 
attention than theyliave lately received. 

Notwithstanding this ostensible object, the author has also put forward 
his own opinions, and such, coming from a man of Mr. Lee's experience 
in the treatmenl of venereal diseases, are entitled at least to a respectful 
consideration, and however much American students of venereal may dilfer 
from the opinions here advocated, they at all events will feel that these 
latter are no idle theories, but the result of an honest belief and ripe expe- 
rience. The first part of the first lecture is devoted to an eulogy of Hun- 
ter's genius (a never-failing source of delight to English surgeons), and 
an attempt to prove that the life of the blood was known to and recog- 
nized by Milton and Shakspeare. He then goes on to discuss the various 
kinds of poisons and their modes of action, and under this head he says 
(pp. 16 and 191):— 

" Some animal poisons affect the skin by simple touch, as those belonging to 
certain sea insects, the ant, etc. The poisons produced by other animals caiv 
not possibly operate unless conveyed into a wound which brings them in con- 
tact with the living principle. They will always act under such circumstances, 
but not when the cuticle is entire. This has, over and over again, been as- 
serted with regard to the syphilitic poison ; but Hunter, as we shall see, took 
a different and more correct view, as will be illustrated hereafter, especially by 
Case VIII.," and "Experience has now taught us that the poison from a sup- 
purating sore applied to the urethra will there produce an ulceration, as on 
any other part; and conversely, that the true infecting syphilitic poison may 
pass through the skin or the cuticle, and produce its effects upon subjacent 
parts without any abrasion." 

Upon turning to Case YHI., we confess to a feeling of unmitigated 
surprise to see upon what iusufficient evidence the attempt is made to 
prove that infection occurred, first loy menstrual blood, and second through 
an uuabraded cuticle. Its importance shall be our excuse for giving it in 
full :— 

" Cask VIII. — A nervous gentleman, who had never had syphilis, had con- 
tact but not intercourse with a lady who had not quite recovered from her 



1876.] Lee, Lectures on Syphilis. 195 

menstrual period. 'I'liere followed considerable irritation of the glans penis ; a 
lymphatic vessel on one side of the peni.s enlarged to the size of a common 
writing quill; one of the corresponding glands in the groin l)ecame as large as 
a chestnut, and painful. Some days after, the frenuin became indurated, but 
there was no induraiiou on the glans penis; a copper-coloured syphilitic erup- 
tion followed, and this in turn was followed by mucous tubercles on the lips 
and tongue. 

"It was subsequently ascertained that the lady had had an old syphilitic 
affection ; there had also l)een a slight herpetic eruption on one labium and on 
a small part of the skin of the face. The disease in this case was communi- 
cated by simple contact, previous to which there was no lesion on the skin or 
mucous membrane of the gentleman. The lady was sonif^ days afterwards care- 
fully e.xamined; there were two or three small, dark-red pimples on the chest; 
tlie vagina was perfectly healthy, but there was a copious, viscid, tenacious 
discharge from the uterus. 

" 'I'hat it was the accidental admixture of blood in this case which deter- 
mined the infection, even if the blood did not convey it, is confirmed by the 
fact that this lady thought herself perfectly well, and had not the slightest sus- 
picion of having had any disease for some years previously." 

In the first place, in the history of the case, one very important link 
has been omitted, viz., whether and when this gentleman had had any 
connection previous to this "simple contact" wliieh produced such "con- 
siderable irritation of the glans penis ?" " Some days after" (after what; 
the contact or the irritation of the glans penis, the enlargement of the 
lymphatic vessel and of tlie inguinal glands?) "the frenuin on one side 
Ijecatne indurated;" it is unusual to have the induration occur so soon 
after coitus, and, most singular thing of all, " there was no induration of 
the glans penis," which had been so irritated, but of the frenuin. If this 
doctrine of inoculation through sound skin or mucous membrane be ad- 
missible, then venereal surgeons run a serious risk every day of their 
lives, and render themselves almost fatally liable to contract syphilis unless 
their hands and fingers are artificially protected. At any rate, we must 
suspend judgment upon this point, if the proof is dependent upon no better 
evidence than this case or others like it. 

The author then goes on to consider the transmissibility of syphilis by 
the blood, and among the more recent experiments undertaken for this 
purpose, viz.. Waller's, Linderman's, Gibert's, Pellizari's, etc., mentions 
two of Uunter's cases, where inoculation occurred from the transplantation 
of teeth ; but whether from these cases Mr. Lee thinks that Hunter re- 
garded the blood as capable of transmitting syphilis, is obscure from the 
text. 

Lectures II. and III. are devoted to discussing the inoculation of the 
secretions of primary and secondary syphilis upon jiersons free from the 
disease as well as upon the bearers of the lesions. Upon the former the 
inoculations produced, as might have been expected, successful results, 
i. e., syphilis ; whereas, in the latter, the result was either negative, or 
else a local, suppurating sore was developed, and this took place especially 
if the lesion from which the matter was taken had previously been irri- 
tated. But even granting the success of the experiment, what does it 
show ? Certainly no fresh infection ; only the fact that the skin in such 
patients is irritable, and capable of being inflamed from trivial causes, as 
is shown by Pick's and Kraus's experiments with the matter of non-spe- 
cific eruptions upon syphilitic patients.^ This Mr. Lee evidently appre- 
ciates, judging by what he says on p. 53. 

' Quoted by Zeissl, Lebrbuch, etc., vol. ii. p 40. 



196 Reviews. [Jan. 

In these two chapters the most notable statements are those bearing 
upon the condition of the mucous membrane of the urethra in syphilis, 
more especially in the earlier stages. In speaking of the serous and rau- 
cous membranes, he says (p. 39) : — 

"They may both become infiltrated, thickened, and permanently altered. 
With regard to the serous membranes, we often see an example of this, as in 
the case of old omental hernife; and with regard to the mucous membranes most 
interesting examples are afforded in illustration of our present subject in the 
formation of raucous tubercles and in the more or less permanent thickening of 
the mucous membrane of the urethra. These will hereafter occupy our atten- 
tion particularly. I will only at present note, that the mucous membrane of 
the urethra may be thickened by the syphilitic poison, as shown by cases similar 
to the following, which in practice are not very uncommon. 

" Case XIV.- — A young gentleman contracted syphilis, followed by secondary 
symptoms. He had never had gonorrhoea. Tn the course of the manifestations 
of the secondary affection, the stream of water gradually diminished. He had 
apparently an ordinary stricture, which was cured by the specific treatment 
without the use of instruments. There was no urethral discharge in this case." 

Again, the tendency to jump at conclusions. The only reason for be- 
lieving in the existence of stricture was the diminution of the size of the 
stream of water; a rather uncertain symptom to base a diagnosis upon, 
inasmuch as such changes occur daily in persons enjoying perfect health. 
No examination was evidently made to verify the diagnosis, as the case 
" was cured by the specific treatment without the use of instruments." 
Mark, it is not urged that there may not have been some irritation of the 
urethral mucous membrane, but we do most decidedly protest against the 
diagnosis of stricture upon such insufficient proof. 

In addition to this syphilitic " stricture" Mr. Lee delivers himself at 
some length upon the subject of "syphilitic discharges from the urethra," 
which are so interesting and suggestive that, at the risk of lengthening 
the review, we shall quote them fully. On p. 62, we find the following : — 

"That ordinary gonorrhoea is not in itself syphilitic and does not produce 
constitutional syphilis, is abundantly proved without inoculation, by simply 
observing the natural course of the disease; but to conclude that no urethral 
discharge unaccompanied by ulceration and which cannot be inoculated,' is 
syphilitic, is entirely a different question. Now 1 have long noticed a peculiar 
kind of urethral discharge which differs in its nature and symptoms from that 
of ordinary gonorrhoea. It occurs not infrequently in patients suffering from 
constitutional syphilis who have not exposed themselves to any fresh infection, 
and it also precedes or accompanies well-marked primary disease in those who 
have. It consists of a viscid grayish secretion often resembling in appearance 
thin oatmeal gruel. It is generally unaccompanied by any pain when the 
water passes, and attracts little of the patient's attention. 

"When accompanied or followed by a Hunterian chancre, it does not appear 
until some days aPer exposure, and will generally cease as soon as the chancre 
is developed. Upon the occurrence of this discharge, I have predicted the 
infection of the general system, and this has been followed by a specific indura- 
tion in one spot on the prepuce, enlargement of the inguinal glands, and syphi- 
litic eruptions over the whole body." "It is very rarely that 

an indurated sore exists within the urethra, although the syphilitic poison 
must often be conveyed there. On the lips of the urethra it not infrequently 
occurs, but in the whole course of my experience, I have never known it to 
originate further back than a quarter of an inch from the orifice; and in the 

1 Upon whom ? The bearer of the discliarge or one free from syphilis ? F. R. S. 



1876.] Lee, Lectures on Syphilis. 187 

fjroiit majority of cases, if it affects tlio urethra ut all. it spread.^ to it from 

without." " It happen.^ every (lay that a young gentleman, who 

has never bad syphilis, will expose himself to contagion with a woman of the 
town, who has long ceased to have any outward manifestations of disease, and 
after the lapse of some days will have a discharge such as I have described, 
or after a still longer period of incubation, some adhesive form of inflammation 
will appear on the unabraded skin of the penis or upon the internal prepuce. 

"The glands in the penis will subsequently become enlarged in a peculiar 
way. which I have called the amygdaloid condition, and in due course the 
whole train of secondary symptoms will follow." 

"The urethral discharge wliich I have described, instead of being one ofthe 
first symptoms of syphilis, will sometimes appear as one of its secondary mani- 
festations." 

After giving the history of several cases, many of them, it seems to us, 
having little bearing upon the i)articuhir subject under discussion, Mr. 
Lee concludes : — 

"That the product of primary syphilis is inoculable artificially, so as to pro- 
duce the same effects as when it was naturally acquired. 

"That the results of secondary syphilitic manifestations ai*e inoculable arti- 
ficially so as to produce the same results, and that the secretions from mucous 
membranes in syphilitic patients are very often the means of communicating 
syphilis, and may sometimes be artificially inoculated." 

Lectures IV., Y., and Yl. are given up to the discussion of the treatment 
of syphilis in all its stages, and although some of the opinions here enun- 
ciated are at variance with the teachings and belief of syphilographers in 
the United States, jet these three chapters cannot fail to instruct, and will 
amply repay attentive perusal. 

In the first place, Mr. Lee objects to the division of syphilis into primary, 
secondary, and tertiary, and tlie consequent belief that secondary symp- 
toms require a mercurial treatment, while the tertiary call for iodine, sar- 
saparilla, and tonics, very justly observing " that practically such distinc- 
tions are of little value, and often lead medical men to treat the name 
which they may happen to apply in a particular case rather than the dis- 
ease itself." If any classification must be used he gives the preference to 
Mr. Lane's, although that even is far from satisfactory. He says : — 

" But I am satisfied that no such classification can be practically relied upon 
either as a matter of pathology or with regard to treatment. A node, for 
instance, which is generally supposed to be among the latest manifestations, 
will sometimes be the first symptom to attract attention ; and, on the other 
hand, I have seen a well-developed syphilitic scaly eruption on the arm of an 
Indian officer, who had had no primary affection for seven and twenty years." 
(p. 80.) 

At the beginning of the chapter, he lays down the following brief rules 
for the use of mercury : — 

" At whatever period of the disease, we find the existence of the specific 
adhesive form of action, whether developing itself as a primary manifestation 
in the shape of an indurated sore, or as an affection of the inguinal glands, or 
in the form of papular, tubercular, or scaly eruptions on the body, mercury is, 
in my opinion, sure, if properly administered, to be beneficial." 

" When the disease, whether primary, secondary, or tertiary, has a tendency 
to produce suppuration in the affected parts, mercury should be administered 
with great caution. 

"The same may be said, as a rule, where the affected parts run rapidly into 
ulceration, although in some of them to be subsequently considered, one form 
of mercurial treatment is wonderfully efficacious. 



198 Reviews. [Jan. 

" Where mortification takes place, whether affectino- minute or larger portions 
of the tissues of the body, mercury, given so as to afi'ect the constitution, is, as 
a rule, injurious." (p. 81.) 

In this country, the use of mercury is generally suspended until the 
appearance of secondary symptoms, for the two principal reasons, that, 
first, it is often doubtful what kind of ulcer is under inspection, and, 
secondly, that, although mercury will often hasten the cicatrization of the 
primary lesion, it also has the property of delaying the appearance of 
subsequent symptoms, and after the treatment has been continued for some 
weeks or even months, upon its remission the surgeon is entirely at a loss 
what next to expect if anything, or what their character will be if subse- 
quent symptoms do occur. 

With regard to its use, even where ulcerations are present, without dero- 
gating from the importance, nay more, the necessity of attending to the 
patient's general health, mercury will be found of great value in the treat- 
ment and especially in checking the extension of the ulceration. Where 
mortification occurs, then, indeed, we liave need to be careful, but here, 
even, we must not necessarily exclude mercury. 

Our author then quotes at length Mr. Pearson's views with regard to 
the use of mercury in syphilis, with which he agrees as to there being "no 
remedy like mercury for the cure of syphilis ;" he then says : — 

" The iodide and bromide of potassium stand pre-eminent among the medi- 
cines introduced since Mr. Pearson's time, but their value consists, in my 
opinion, in removing symptoms, not in curing them. I am. of course, aware 
that after a person has once had syphilis an impression is left upon his system 
which is not effaced for years, and perhaps not at all, and what I mean, tliere- 
fore, by a patient being cured is, that he shall have no further manifestations 
of the disease. That this condition is often obtained by a proper course of 
mercury, I cannot doubt." (p. 84.) 

The quotation which our author makes from Sir Benjamin Brodie upon 
the use of mercury is, in the main, excellent, and is worth studying in com- 
parison with the improved methods of treating the lues venerea in vogue 
at the present day. 

Mr. Lee next passes to a consideration of the various preparations of 
mercury, of which he gives the following : For internal use, blue pill, calo- 
mel, and corrosive sublimate, as well as the iodides and bromides of mer- 
cury. Externally, inunctions with the mercurial ointment or the oleate of 
mercury, and fumigations by the gray oxide and the bisulphuret. The 
latter seems to be his favourite method of treatment. 

Of the internal method, Mr. Lee appears to have but a moderate opin- 
ion, if we may judge from the following paragraph (p. 89) : — 

" On account of its convenience and the little trouble it gives, the adminis- 
tration of mercury in the form of pills is that which the patient prefers. But 
mercury can seldom, if ever, be given in this way long enough to cure the dis- 
ease. It acts upon the patient's stomach and intestines before it has accom- 
plished its object, and it has then to be discontinued. It may. for a time, be 
usefully employed either by itself or in combination with external treatment. 
Three grains of blue pill, with half a grain of opium, night and morning, or 
half a grain or a grain of iodide of mercury with a quarter of a grain of opi- 
um, night and morning, are convenient ways of giving mercury internally, and 
will, in general, soon produce its specific action. The corrosive sublimate or 
perchloride of mercury can never be trusted to for the cure of syphilis, 
although it is a valuable auxiliary in some stages of the disease." (p. 89.) 



1876.] Lee, Lectures on Syphilis. 199 

There is no douI)t that tlie exceptions to tlie internal treatment as taken 
by Mr. Lee are well founded, for it is frequently found that the stomachs 
of patients become deranj^jed by the medicines lonp before the disease is 
cured, and we are specially ])leased to find that Mr. Lee's opinion of the 
value of the corrosive sublimate so closely coincides with our own. An 
excellent rule in the treatment of syphilis, but one, alas ! too frequently 
lost sifiht of, is, that the skin is for medicine ; the stomach for food. And 
this brings us to the section on inunction of mercurial ointment; a plan 
recommended by both Mr. Pearson and Sir Benjamin Brodie. 

"Tliis answers very well if a patient will carry it out, but it is not often in 
private practice that this can be accomplished. It involves a consiilerable 
amount of trouble, and the patients object to the dirty appearance on their 
skin and on their clothes. This last objection has of late been partially re- 
moved by the introduction of the oleate of mercury." (p. 89.) 

This point of dirt and greasiness is a very serious one and limits the 
usefulness of an otherwise admirable method of treatment, but even this 
disadvantage may be in a great measure overcome, if not entirely removed, 
by applying the ointment to the soles of the feet. The way of doing so 
in this country is as follows : — 

The patient is directed to take a hot foot hath on the first evening of 
the i^iunction cure, and after the skin of the feet has become supple and 
soft, from a half to a full drachm of the ung. hydrarg. (U. S. V.), is 
thoroughly rubbed into the sole of the right foot. A clean pair of thick 
socks are then put on, which are to be worn day and night for this course 
of inunction, which lasts from seven to fourteen days at a time. Upon 
the second evening, the left is anointed in a similar manner, on the 
third evening the right foot again, and so on, each foot getting its dose 
on alternate evenings. Each course of inunction lasts from seven to 
fourteen days, and even longer if occasion requires it, but it is well to 
suspend its use at the end of the fortnight for a few days, when the 
patient washes off the residue of the ointment and puts on fresh socks. 
This way presents several advantages : first, greater cleanliness, and second, 
less trouble, for after the first inuction each successive dose of the ointment 
gets rubbed in by the friction of the foot in the stocking, and the sock 
saturated with the ointment keeps the mercury in constant application to 
the skin. We are moreover convinced that absorption does take place, 
notwithstanding the thickness of the skin in that place. In this country 
it is unusual to confine the patient to his room, much less to his bed, 
as mentioned on p. 90. Of course due precautions are taken against 
catching cold, but beyond that, the patients are directed to take plenty of 
out-door exercise. 

Fumigation is the next method discussed by Mr. Lee, and upon this 
head his remarks are very judicious. Fumigations have often received a 
bad name owing, in a great many instances, to their being improperly 
given, and it is against these sources of error that Mr. Lee raises his voice. 
He says : — 

"In the first place, it is the calomel bath, which T have recommended in the 
treatment of syphilis, and not a vapour bath. The water used is only for the 
purpose of softening and diluting any irritating vapour that may arise when 
the calomel is sublimed, and for this purpose half an ounce or an ounce is sufB- 
cieut. I find it is very common for a considerable quantity of water to be used ; 
as this boils a certain amount of heat necessarily becomes latent, and as the 
vapour recondenses on the skin this latent heat is again given out-. The result 



200 Reviews. [Jan. 

is often a profuse perspiration. A double evil results from this : the perspira- 
tion washes the calomel oS' the skin where it should remain; and to a certain 
extent debilitates the patient. How many patients sufifering from syphilis are 
already much reduced with regard to their physical powers, and will not bear 
any remedies of a depressing nature. A daily vapour bath becomes a tax upon 
the constitution of such patients, which is a very serious addition to the causes 
of debility under which they already labor." (p. 92.) 

Mr. Lee then describes at length the form of the bath and the manner 
in which he uses it. 

With regard to the question when to begin the mercurial treatment 
which was discussed a short distance back, it may not be inapt to quote 
Mr. Lee's words as to his own method, comparing it with the plan pur- 
sued in the United States. He writes : — 

" For primary syphilis occurring in a patient for the first time, uninfluenced 
by the existence of previous disease in himself or by hereditary influence of the 
same kind. I seldom now discontinue the treatment under three months, and I 
generally explain to the patient to begin with, that unless he is prepared to 
follow such a course he had better wait until the secondary symptoms and then 
undergo his treatment." (p. 101.) 

In Lecture V. Mr. Lee gives himself more especially to the considera- 
tion of the treatment of particular and modified syphilitic affections, be- 
sides describing the symptoms which occur upon the skin, mucous mem- 
branes, etc. On pp. 105, 128, and 129, he describes a peculiar affection 
of the mouth which " occasionally though rarely" occurs. This " re- 
sembling salivation will be one of the first manifestations of constitutional 
syphilis even in those who have not taken any mercury." In one case, 
this affection together with the other symptoms subsided under the use of 
mercury. 

In speaking of suppurating syphilitic eruptions of the skin, our author 
is of the opinion that the mercurial action will not be borne so well, and 
may with great advantage be combined with some tonic medicine adminis- 
tered internally, such as bark, "nitric acid, iron, and sarsaparilla." 

In discussing the treatment of the phagedenic ulcerations we are sur- 
prised to see the entire omission of the potassio-tartrate of iron, both 
externally and internally, Mr. Lee giving the preference as a local dress- 
ing to a "lotion of the sulphate of copper and extract of opium, each five 
grains to an ounce of water. 

Our author speaks again, p. 12.5, of a urethral discharge coming on 
in the course of syphilis without any other cause to account for it than 
the syphilis, and being cured by anti-syphilitic treatment. 

Under the head of treatment of sy])hilitic affections of the bones, Mr. 
Lee speaks almost enthusiastically of the use of sarsaparilla alone, if given 
properly and in sufficient quantity. He reprobates the habits of many of 
the London chemists, who in making up the decoction, which he, Mr. Lee, 
prefers, use the extract. He candidly acknowledges, p. 138, that " in 
many cases, however, sarsaparilla will not cure the disease, or relieve the 
sufferings of the patient," nor does it exert much, if any, benefit over the 
eruptions of the skin. 

Our author's remarks upon the iodide of potassium coincide in the 
main with the experience of American surgeons. He allows its efficacy in 
relieving nocturnal pains in the bones, but says it cannot in his experience 

" be relied on in the same way as mercury can for the permanent removal of 
the manifestations of the secondary or so-called tertiary forms of syphilis. It 



1876.] Lee, Lectures on Syphilis. 201 

often appears to remove the symptoms for a time, but it does not cure the 
disease." (p. 151.) 

He advises its use generally in from three to five grain doses three times 
daily, but allows that " in oI)Stiiiate cases very large doses are often given, 
as much as ten or fifteen or thirty grains three times a day ;" l)nt, he adds, 
"it is doubtful whether these doses possess any advantage over the 
smaller ones" (j). 153), — an opinion diametrically opposed to experience 
on this side of the water, where a dose less than ten grains is seldom 
given, and not infrequently a dose double his largest one ; the belief l)eing 
that small amounts of the salt are comparatively worthless. After speak- 
ing of the advantages derived from the combination of opium with mer- 
cury, and its action in the treatment of syphilis, Mr. Lee passes on to the 
consideration of the "local suppurating venereal sore," the "chancroid" 
of the French, and commences the chapter with the statement that " the 
local suppurating venereal sore has never been known, so far as I am 
aware, from personal observation, to infect a patient's constitution so as 
to produce secondary symptoms," an admission which, with few excep- 
tions, English writers on venereal are loath to make, one of the chief 
stumbling blocks being the adoption of the name "soft" chancre instead 
of "simple" chancre. Our author gives a good description of the char- 
acter of this lesion and its treatment, but there is nothing specially note- 
worthy in his remarks, and he furthermore mentions syphilization to con- 
demn it. Mr. Lee also devotes several pages to the discussion of " lym- 
phatic absorption," and the condition of the inguinal glands in the early 
stages of syphilis, of which he writes, that 

" the conJition of the ioguinal glands which I have called amygdaloid is a very 
important, and I would say the most characteristic symptom in the tirst mani- 
festations of constitutional syphilis," and "if their origin and progress is 
watched, they afford, as 1 believe, a correct indication of the condition of the 
patient's constitution as regards syphilitic disease, and I believe that no patient 
can be said to be free from syphilis or fit to marry so long as they remain" (p. 
169). 

Lecture YIII. treats of urethral discharges, and the different kinds, to- 
gether with their treatment, and here our author states very distinctly that 
every discharge from the urethra is not necessarily gonorrheal (i. e. due 
to coitus), and calls attention to the fact that certain articles, viz., pepper, 
guaiacum, and beer, as well as the rheumatic and gouty diatheses, are 
capable of inducing a discharge from the urethra in no wise differing from 
one due to coitus. 

Under the head of stricture, Mr. Lee reverts more fully to what he had 
already said on pp. 39 and 40, with reference to the part that syphilis 
plays in the production of stricture of the urethra. He says, p. 189 : — 

" Now, I wish here particularly to guard myself against being misunderstood. 
A very great number of strictures arise, 1 doubt not, from the effects of in- 
flammation consequent upon an ordinary gonorrhoea, or some other non-syphi- 
litic affection. But there are others which .arise in sypilitic constitutions, and 
some of them, as I believe, in direct connection with syphilitic disease of the 
lining membrane of the urethra. The time at which thickening around the 
urethra occurs lends some suppo;"t to this view. It is not, as Hunter remarks, 
during the time that the inflammation lasts, but after it has subsided that the 
deposit takes place ; or, in other words, at the time when deposits of lymph 
from secondary syphilis might be expected in other parts of the body. Cases 
of gonorrhoea are so mixed up together, as observed in practice, that it is often 
exceedingly difficult to say to which any consequent chronic affection of the 



202 Reviews. [Jan. 

urethra should be assig-ned. But T think I .should be safe in aspertinp that if 
10(10 patients were taken who had had gonorrhcEa alone, and 1000 who had had 
gonorrhoea and syphilis, that stricture would be found much more 'commonly 
in the latter than the former;' and on p. 190 he furthermore says — 

"In France, M. Baumfes and M. Layneau still treat blenorrhagia with mer- 
cury. Strictures, as such, have not often been thus treated ; but I am satisfied 
that there are a certain number of these which can be permanently cured only 
by constitutional anti-syphilitic treatment." 

We have already expressed our dissent from this view, although we can 
readily conceive of a possible constriction of the urethra as the result of 
an indurated urethral chancre, but these Mr. Lee believes to be rare, and 
moreover, they would by no means cover the number of cases to wliich he 
here refers. 

Under the head of treatment, our author speaks highly of the internal 
use of copaiba, than which there is, in his opinion, no remedy given in- 
ternally which influences some of these discharges so much. He depre- 
cates its continued use for any great length of time, as it is apt to irritate 
the kidneys. Curiously enough, not a word is said of the use of the 
sandal-wood oil. 

In Chapter IX. prostatic discharges and their treatment is discussed, in 
which there is nothing noteworthy except the use of the perchloride of 
iron in such cases. "A solution of from 2-4 drachms of the liquor ferri 
perchloridi to eight ounces of water is used. A catheter with openings 
at the end, and a piston in its straight (not its curved) part is charged 
with some of the fluid, and introduced so that the orifices in the instru- 
ment may rest in the prostate gland, and the piston is then thrust forward 
so as to expel the contents of the catheter." 

The tenth lecture on lymphatic absorption and its treatment, warts 
and excrescences, ends a book which no medical man reading through, can 
lay down with the feeling that he has wasted his time, no matter how 
much he may dissent from the views set forth, a verdict, by the way, which 
can be rendered in but few of the many medical treatises written at the 
present day. F. R. S. 



187 6.1 '203 



ANALYTICAL AND BIBLIOGRAPHICAL NOTICES. 



Ap.t. XX.— Gni/'s Hospital Rcporfa. Edited by H. G. ITowse, M.S.. and 
Fkkderick Taylor, M.D. Third Scries. Vol. XX. [With a General 
Index to Vols. XI.-XX.J 8vo. pp. xviii., 624. London : J. & A. Churchill, 
1875. 

TiiK present volume of this admirable series contains, as has each of its 
predecessors, a large number of valuable papers, of which we shall accordinof 
to custom endeavour to give our readers some notion, so as in some degree, at 
least, to supply the want of those who may not have the opportunity of con- 
sulting the work itself. 

Taking up first those papers which are particularly addressed to Surgeons, 
we are met at the outset with a continuation of M r. J. Coopkr Forster's annual 
contribution of Surgical Records. Eighty-one cases are here narrated with 
more or less detail, and an index is appended which greatly facilitates reference 
to any of the rather multifarious subjects with which the author deals, 'i'he 
class of cases which Mr. Forster meets with in Guy's Hospital seems to be 
very similar to that seen in large surgical hospitals in our own country, and 
the modes of treatment do not seem to be essentially different. Four cases of 
vesical calculus are related — one relieved, but not cured, by lithotrity, and three 
treated by lithotomy, two (in children) successfully, and one which terminated 
fatally, its chief feature of interest being the large size of the stone, which 
weighed eight and three-quarter ounces. The operation in this case was 
followed by free bleeding, and though a vessel could be seen spouting and could 
not be twisted, ligation does not seem to have been thought of, the operator 
preferring to employ digital pressure for three hours, and then, hemorrhage still 
continuing, to plug the wound with an " umbrella plug," which, we suppose, is 
Guy's English for a " canule ct chemise." Though this mode of treatment 
probably did not hasten the fatal issue, it does not, we must confess, seem to 
us to have been that best adapted to promote recovery. 

Mr. Forster devotes a page and a half to the subject of Esmarch's so-called 
" bloodless method," the advantages of which he considers to be numerous, 
while its ill effects he deems " hardly appreciable ;" upon which we have to 
remark that while the benefits to be derived from the use of the tube and 
webbing are in many cases incontestable, the dangers of their employment in 
other cases are at the same time real, and their applicability by no means so 
general as has been claimed by Esmarch and his followers. Apart from the 
risk of paralyzing the member to which the tube is applied (a risk to which 
Mr. Forster does not even allude), the danger of troublesome and even fatal 
consecutive bleeding is, we are convinced, more serious than is commonly sup- 
posed. The present writer is personally cognizant of a case in which a most 
accomplished surgeon employed the " bloodless method" in an excision of the 
knee-joint ; when the tube was removed almost no bleeding was apparent, and 
accordingly after tying (seemingly without necessity) one or two superficial 
branches, the limb was put up and the wound closed ; in a few hours, however, 



204 Bibliographical Notices. [Jan. 

the dressings became stained with blood, and from that time, though cold was 
applied, the limb elevated, and at last the wound opened and stuffed with lint, 
capillary oozing continued until the death of the patient in about forty-eight 
hours from the time of the operation. 

A Form of Muscular Asthenopia, is the title of a short paper communicated 
by Mr. Charles Higgens, F.R.C.S. The peculiar form of asthenopia here 
described is often mistaken by the patient (and sometimes by the practitioner) 
for incipient cerebral disease, and hence its early recognition is a matter of 
considerable importance. The subject is not a new one in this country, Dr. S. 
Weir Mitchell having already directed attention to the matter, in the numbers 
of the Medical and Surgical Reporter for August 1, 1874, and February 6, 
1875. 

"The symptoms complained of are somewhat peculiar, and depend on want 
of power in the internal recti muscles, in cases of hypermetropia complicated 
by strain of accommodation. Pain in the head generally is complained of, but 
it is usually experienced with greatest severity in the brows ; it is not simply 
the feeling of uneasiness and tension accompanied by inability to look long at 
a near object without its becoming indistinct, met with in simple hyperme- 
tropia, but is usually described as of a drawing pinching character, at times so 
severe as to i-euder near work impossible. The pain is at first only noticed 
occasionally, and that after long and close application ; it disappears after a 
night's rest, but most likely returns again towards the end of the next day. 
This state of things may continue for some time, but sooner or later the pain 

becomes constant A somewhat peculiar disturbance of vision is 

complained of, not simply the dimness experienced in hypermetropia, but 
a kind of lateral drawing out of a near oloject, terminating after a time in 
complete crossed diplopia, single vision being restored on making an effort ; 
the effort, as also the maintenance of a single image, being accompanied by pain 
more or less severe. Giddiness is also a frequent symptom of this form of 
asthenopia; .... not unfrequently these patients present a peculiar, 
worn, tired expression not easily described, and have a tendency to frown when 
any effort of convergence is made." 

We have quoted the author's account of the symptomatology of the form of 
asthenopia referred to, thinking it might be of interest to those of our readers 
who pay no particular attention to diseases of the eye, and who, therefore, may 
not be familiar with the affection in question. Its treatment is the same as 
that of other forms of muscular asthenopia, and consists in the adaptation of 
suitable glasses, directions for choosing which may be found in works on oph- 
thalmic surgery. 

The next paper to which we shall refer is A Description of the Appearances 
of the Human Eye in Health and Disease as seen by the Ophthalmoscipe ; 
Eighth Series — Displaced Retina ; by C. Bader. The present number of Mr. 
Bader's series is illustrated by three chromo-lithographic figures, showing (1) 
displacement of the greater part of the retina with atrophy of the optic disk ; 
left eye; (2) displacement of about one-third of the retina, the optic disk ap- 
pearing nearly healthy ; right eye, as seen in rayopics ; and (3) the appearance 
of the part of the fundus (choroid and retina) of an eye which, two years before 
the sketch was taken, had been operated on for displaced retina. 

We come next to a second brief paper by Mr. C. Higgens, entitled Remarks 
on the Ophthalmoscopic Appearances met with in Intracranial Disease. 
The author begins this paper, of which the value is by no means to be estimated 
according to its length, by pointing out that though optic neuritis and ischye- 
mia (choked disk) may each occur without the existence of any disease within 
the skull, j'et that when either is found affecting both ci/es sinudtaneousli/, 
strong presumptive evidence is afforded of the existence of some intracranial 



18VC.] Guy's Hospital Reports. 205 

lesion, even thoneh no subjective cerebral symptoms be observed. Tlie oph- 
thalmoscopic ditrereuces between the two atlections are given by Mr. Higgens 
as follows : In iieurid's the disk is gray, opaque, and somewhat swollen ; the 
retina, for some distance around, swollen and infiltrated with gray and opaque 
inflammatory material ; and the retinal veins enlarged and tortuous, the arte- 
ries being smaller than normal, and the number of visible vessels less than in 
health, many of them too being shrouded and concealed from view in parts of 
their course by the inflammatory exudation. In ischcemia, or choked d/sk, on 
the other hand, the disk is red, resembling the surrounding choroid in colour, 
greatly swollen, projecting considerably into the vitreous chamber, and with 
its area increased ; but its transparency is only slightly affected. The surround- 
ing retina is but slightly afiected, not opaque, but simply cedematous and 
swollen. 'I'he retinal veins are enormously distended, and their visible number 
increased ; the arteries are small ; none of the vessels are entirely hidden in any 
part of their course, but portions may appear darker or lighter as they lie more 
or less deeply in the substance of the cedematous retina ; a bend may be noticed 
in the vessels where they pass over the border of the swollen disk. 

The most important subjective difference is that in optic neuritis there is 
always great impairment of vision, while in choked disk liltle or no want of 
sight is complained of, unless inflammatory or atrophic changes follow secon- 
darily. The reason for this is obviously that in neuritis the trunk of the optic 
nerve is itself affected, the inflammation, indeed, commonly beginning in its 
intracranial portion (descending neuritis), while in choked disk the intraocular 
portion of the nerve is alone involved, becoming strangulated, and dropsy of the 
optic disk and surrounding retina ensuing, but there being nothing to prevent 
the normal conduction of impressions formed on healthy portions of the retina, 
as for instance on the yellow spot. 

As regards the respective significance of optic neuritis and choked disk, 
Mr. Higgens says : — 

"Optic neuritis, as before stated, commences in the trunk of the nerve be- 
hind the eyeball, and is caused by direct irritation. 1 would therefore suggest 
that, in cases where the ophthalmoscope shows influramaliou of the optic disc, 
some disease about the base of the brain or skull, such as meningitis, peri- 
ostitis, or caries should be suspected. Ischiemia depends upon and is a visible 
sign of obstruction to the return of venous blood from the eyeball, and may 
be caused, I think, by any intracranial att'ection, tumour, etc., which gives rise 
to overcrowdi'vg of the contents of tlie skull, or possibly by any disease which 
causes permanent congestion of the head." 

The next paper which demands our attention is a Report on Operative Sur- 
gery {luith Illustrations) ; Part II., On Cancerous Tumours of Bone, by 
Thomas Bryant. To understand Mr. Bryant's excellent paper, which, as we 
remarked in noticing the first part of his report (see No. of this Journal for 
January, 187.1, p. 201), seems to us a model of the kind of papers which Hos- 
pital Reports sliould contain, it must be observed that in common with most 
English writers he employs the word cancer as correlative simply with the 
term malignant growth, and not with reference to the structural or histogenetic 
characters of the tumours of which he speaks. Thus he declares that cancer 
may occur in bone as a primary affection, which, according to the view advo- 
cated by Thiersch, Waldeyer, and Billroth, and which seems to be daily gain- 
ing more adherents, is, of course, impossible; cancer (or, to speak more pre- 
cisely, carcinoma) never, according to these writers, originating save in 
epithelial tissues. Indeed Mr. Bryant's own cases tend to support this doctrine, 
for of the two tumours which he describes as " cancer originating in bone," one 



206 Bibliographical Notices. [Jan. 

he himself calls a round-celled sarcoma, and as to the other, though he ?ays 
that " as a type of the medullary cancer it is very good, and as an example of 
its infiltrating and cancerous action it is of no less value," yet he quotes from 
Dr. Goodhart's microscopical report that it had " a very clearly set small round 
cell-growth, and must . . . be looked upon as a medullary sarcoma." The 
first mentioned case (round-celled sarcoma of tibia) is particularly interesting, 
as furnishing at once an instance of a sarcomatous growth spreading by way of 
the lymphatic glands, and of embolic metastasis to the liver. Mr. Bryant's 
paper gives in all the details of eleven cases, and is adorned with no less than 
seven remarkably well executed lithographic plates. 

On Cancer, as Illustrated in Ichthyosis of the Tongue and allied Diseases, 
resulting from Prolonged Local Irritation, is the title of a paper of twenty- 
four pages, contributed by James F. Goodhart, M.D. In the author's opening 
sentence he says : — 

" It may seem unnecessary, nay even prejudicial, to add to an already over- 
stocked literature of new growths by enumerating individual opinions of a 
hypothetical nature as to the origin of tumours." 

A proposition which we are quite disposed to affirm. Indeed, with the di- 
versity of opinion as to the whole subject of the pathology of tumours (a di- 
versity which, as we have seen, prevails even among the several contributors 
to Guy's Reports), we cannot but think such a paper as Dr. Goodhart's, in- 
teresting and well written as it is, more adapted to increase than to lessen the 
confusion which now surrounds the subject. That which, in our judgment, is 
needed, and which it should be the aim of pathologists to supply, is some 
means of connecting definite clinical characters with recognized structural pe- 
culiarities. Practical surgeons, or at least most of us, have long given up the 
notion that a cancer can be at once recognized by its "malignant appearance;" 
we have reluctantly abandoned the search for a definite " cancer cell ;" and 
have humbly submitted to being bluffed off from our favourite study of '' cancer- 
juice." But it affords little satisfaction to be told that a particular tumour is not 
cancerous but sarcomatous, or that it belongs to the connective-tissue, and not 
the epithelial, type of neoplasms, when recurrence and a fatal issue follow just 
as surely as if it were the most carcinomatous of cancers. What practical 
good then can come from Dr. Goodhart's ingenious suggestions as to the '• va- 
riation of tumours under judicious cultivation," and as to the probability of a 
cancerous growth being an example of the '' survival of the fittest ?" 

Dr. Goodhart's last paragraph is, however, so practical, and withal so just, 
that after finding fault with the rest of his paper, we feel bound to transcribe it 
in full. 

"But faith," he says, "without works, is dead; therefore, with regard to 
ichthyosis of the tongue and allied diseases, a living faith says. Extirpate at 
once in the persistent forms of the disease. Here is an aflection which can 
be recognized before it has become cancerous; the very stage the surgeons 
are all on the look-out for, and which, facts show, will be succeeded by 
one of cancer. Surely then no waiting should be allowed. Cut out while 
there is yet time; but then not only so, but to the earlier stages of ichthyosis 
attention must be directed. I cannot but think that, if it could be seen at its 
onset, it would be amenable to less severe measures than that of the knife or 
ecraseur, but causing, as it does, at first so little inconvenience to the ])atient, 
it is in many cases past cure by mild measures before it is recognised. 'I'ue 
failure of early recognition is, of course, not at our door, but the remedy is, in 
the inculcation of tlie doctrine that local causes play a large and necessary 
part in the production of cancer. Did we but keep this plainly before ourselves 
and our patients, it is no unreasonable hope that external cancers might event- 



187G.] Guy's Hospital Reports. 207 

ually disappear from our nosoloiry just as chimney-sweeps' cancer would ap- 
pear to be dimiuishiuu, uow that the local irritant is less coustuiit than it was. 
At any rate more pood would seem to promise from a belief in the local than 
in the constitutional ori<iin of cancer. For the latter doctrine has in it so much 
of mere fatalism that it is encouraging neither to the surgeon nor his patient." 

Following Dr. Goodhart's paper come Two Cases of Varicose Veins of the 
Lower Extremity treated by Excision ; by N. Davik.s-Colley, N. C These 
cases were treated by cutting away the diseased portions of vein, hemorrhage 
being prevented by means of catgut ligatures, and the operation and after- 
treatment being in each case conducted with antiseptic precautious after the 
manner of Trof. Lister. The results were successful, but not more so probably 
than might have been obtained by the much simpler operation of Mr. Henry 
Lee, which if, as Mr. Davies-Colley declares, it be " not altogether exempt from 
danger," is at least not more perilous than the somewhat heroic plan of total 
excision. The latter operation is really, as pointed out by Mr. Davies-Colley, 
an old mode of treatment, having' indeed been recommended by Celsus. It has, 
notwithstanding, as our readers doubtless know, been within a short time 
loudly heralded in the English journals as the " new" operation introduced by 
Prof. Marshall, of University College. 

On the Operation of Tracheotomy in Childhood, is the title of an eminently 
practical paper contributed by the surgical editor, Mr. IL G. Howse, M.S. — 
The author advises that in the operation of tracheotomy, after malving the pre- 
liminary incisions, the knife should be plunged in with its edge turned upwards, 
at the very bottom of the wound {i. e. nearest its sternal extremity), and tliat 
the surgeon should then 

"cut upwards along the median line of the trachea, j^e^er o?Jce re??ioy/?/(/ it/ie 
knife from the orifice in the trachea, until, what appears to be, to the iiiexpc- 
rienced touch, a most unnecessarily long incisioii has heen made. . . . The 
sensation," he adds, " which is always communicated to my own hand under 
these circumstances, is as if I were slitting up the whole traciiea to the cricoid 
cartilage, though in practice I have never found that 1 have made a larger in- 
cision than through three tracheal rings, and very often smaller." 

A second practical point on which Mr. Howse insists very strongly, is that 
the tube employed should be the very largest lohich loill fit the trachea ; for 
want of a sufficiently large tube the patient often perishes, a state of slow and 
insidious asphyxia being produced, during which the lungs become gradually 
engaged, and pneumonia ultimately supervenes, with a fatal result. Moreover, 
as Mr. Howse clearly shows by means of a diagram, a small tube is much 
more apt to tilt, causing ulceration of the front wall of the trachea, and, per- 
haps, perforation of the innominate artery. Mr. Howse performs tracheotomy 
without the aid of ansesthesia, and after the operation places the patient in a 
" steam chamber," made by surrounding a crib with screens and curtains, and 
introducing a metal pipe which communicates with a suitable boiler, and when- 
ever, as sometimes happens from stiffness and loss of sensibility in the epiglottis 
and neigbouring parts, fluids taken into the mouth escape through the wound, 
resorts at once to feeding through a catheter. His mode of treatment is cer- 
tainly attended with more than an ordinary proportion of success, for of the 
seven cases upon which this paper is based, six terminated in recovery. 

The next paper, which is furnished by Mr. N. Daviks-Colley, M. C, gives an 
account of a Case of Partial Resection of the head of the Humerus, followed 
by Unimpaired Movement of the Joint. The patient was a lad of fourteen, 
and the operation, which was performed with antiseptic precautions, resulted 
in the preservation of a very useful limb, the "' ove.hand" motions being par- 



208 Bibliographical Notices. [Jan. 

ticularly well maintained. AVe think Mr. Davies-Colley hardly does systematic 
writers justice when he says that: — 

•' The possibility of only a part of the articular surface being affected by 
caries or necrosis appears not to have been contemplated by the authors who 
have written upon resections." 

On the contrary, we believe that the reason that total is generally recom- 
mended in preference to partial excision, is simply that the accumulated 
experience of the profession shows that the more sweeping operation gives, 
upon the whole, better results than the "nibbling and grubbing" procedure, 
as ]\[r. Liston would have called it, of taking away merely the diseased struc- 
ture. Mr. Davies-Colley's paper is adorned with a lithographic plate. 

A second paper by Mr. Howse is On a Case of Genu Valgum treated by 
Excision of the Knee-joint. The deformity in this case (which is illustrated 
with two lithographic plates) was caused by the unusual development of the 
outer, and the almost total deficiency of the inner femoral condyle. The 
patient was a girl twelve years of age, and the operation, which presented no 
features calling for special comment, resulted in securing a straight and useful 
limb. 

On the No7-mal Arrangement of the Brachial Plexus of Nerves, is the title 
of a paper communicated by Mr. R. CiiEMEXx Lucas, B. S., which, it seems 
to us, would have been more appropriately placed in such a work as the 
Journal of Anatomy and Physiology than in the Guy's Hospital Reports. 
Mr. Lucas's dissections have led him to believe that the normal arrangement 
of the brachial plexus is different from that described in the ordinary text- 
books, and that it is correctly given in the large work of Henle. Mr. Lucas's 
paper is accompanied by a plate. 

Short Communications, is the general title of a group of papers contributed 
by Mr. W. Laidlaw Purves, on Trepanation of tlie Membrana Tympani, on 
Hereditary Syphilis, on Siegle's Speculum, and on Tinnitus ; by Dr. Frederick 
Taylor, on a Case of Deficient Septum Ventriculorum with Cardiac Murmur; 
and by Mr. H. G. Howse, on Trephining for Pressure Symptoms in Fractured 
Base, and on the Method Employed for the Preservation of Subjects for the 
Dissecting Room. J. A., Jr. 

We shall next call attention to the medical papers in the volume. The first of 
them is by Dr. George H. Savage, who gives us the results of his Observations 
on the Insanity of Pregnancy and Child-birth, which show that 207 female 
patients out of 1333 treated at the Bethlem Hospital, from the year 18G4 to 
1874, owed their insanity to causes related to pregnancy or child-birth, that is, 
14.7 per cent, of the female admissions; the cases range themselves naturally 
in four groups, as follows : 1 insanity with pregnancy ; 2 insanity during labour; 
3 insanity after delivery; 4 insanity due to lactation; of the 207 cases, 10 
belong to the first group ; 2 to the second ; 28 to the fourth, and the remainder 
to the third. Hereditary tendency seems to be the most potent of the predis- 
posing causes, it having existed in 65 out of the 207. Anajmia and exhaustion 
also predispose to this form of insanity. 

The prognosis in this form of insanity appears to be very favourable, not 
only as regards the life of the patient, but also her ultimate restoration to 
health. The treatment consists mainly in the administration of tonics, among 
which iron seems to hold the first place. 

In a paper by Dr. S. 0. Habershon, entitled Some Clinical Facts connected 
with the Pathology of the Pneumogastric Nerve, the histories of several cases 
are given in order to prove, what we fancy no one now denies, that morbid 



1870.] Guy's Hospital Reports. 209 

conditions of ihe stomach may arise, which are due wholly to the state of the 
nervous supply. 'I'hcse conditions are 1. (iastralgia ; 2. Nervous vomiting; 
'^. Nervous flatulence; 4. Nervous loss of appetite, the anorexia nervosa, of 
Sir W. r.ull. A marked peculiarity, which they all possess when they occur 
under these circumstances, is that of alternating with functional derangements 
of organs supplied by other branches of the pneumogastric. Thus we fre- 
quently have violent vomiting and gastric irritation, followed by loud cough or 
loss of voice. 

The cerebral attachments of the nerve are scarcely less elaborate than its 
peripheral distribution, and consequently, any irritation occurring either at the 
peripheral distribution of the nerve, or at its centre, is capable of giving rise 
to wide-spread disturbance. In this way is to be explained the vomiting which 
so frequently accompanies cerebral disease ; tubercular meningitis, for example. 
The author has, moreover, seen cases in which the same symptom occurred as 
a consequence of prolonged anxiety, and yielded only when the cause for this 
had ceased. 

Under the heading of Toxicological Cafes, Dr. Stkvensox reports the history 
of a family who were poisoned by using as a receptacle for water a pail, which 
had formerly contained a sheep-dipping composition. The bucket had l)ecn 
previously, it is said, scrubbed and rinsed with water. Notwithstanding which, 
however, it was found to be coated at the bottom with a greasy mixture of 
soft soap, arsenious acid, and sulphur. Water allowed to remain in it soon 
became largely charged with arsenic in solution. Every member of the family 
suffered from symptoms indicating arsenical poisoning, and in five instances 
death was produced. In addition to pain in the abdomen, vomiting and diar- 
rhoea ; the following symptoms were also observed : conjunctivitis, a papular 
eruption on various parts of the body, headache, and convulsions ; the last 
showing the profound impression the poison exercises upon the central nervous 
system. The viscera of two of the victims were examined chemically, and 
found to contain small quantities of arsenic. 

The paper concludes with an account of a case of poisoning by creasote, in 
which a very large amount of the substance must have been swallowed, for the 
quantity excreted with the urine was seven or eight times as much as would 
form a safe medicinal dose. The urine was quite unlike the ordinary secretion, 
resembling milk and water to which a little ink had been added. When the 
liquid was exposed to the air, the blue-black colour gradually deepened. 'I'he 
patient, a woman, made a speedy recovery, and. although far advanced in 
pregnancy, did not miscarry. The principal symptoms were, unconsciousness, 
stertorous respiration, lividity, and frothing at the mouth. 

Dr. C. Hilton Fagge contributes a paper founded upon Observations on 
some Points connected with Diseases of the Liver or of the Peritoneum, which, 
although it contains little that is not generally known, presents the subject in 
an attractive form. Jaundice is so frequent an accompaniment of hepatic dis- 
eases that it is, of course, thoroughly discussed by the author, but it is to be 
regretted that he is unable to throw any light on the pathology of those cases 
in which the gall-ducts are found to be patent after death. The irritation 
caused by gall-stones has appeared to him occasionally to be the starting point 
of cancerous disease of the gall-ducts. In relation to this point, he says 
•' within the period of twenty-one years, already referred to, there have been 
at least twelve cases in which, gallstones being present, there has been like- 
wise malignant disease of these structures. In some instances the clinical 
history has pointed distinctly to the view that the jaundice was originally due 
to an ordinary attack of biliary colic, and that the development of cancer was 
No. CXLL— Jan. 1876. U 



210 Bibliographical Notices. [Jan. 

secondary; indeed, one case seems to admit of no other interpretation." A 
good many pages are also devoted to tbe consideration of diabetes — a disease 
which he regards as invariably due to an increased flow of sugar from the liver 
into the blood, or, in other words, to an excessive activity of the glycogenic 
function of this organ. He shows, by arguments which seem to us convincing, 
that it can rarely if ever depend either upon the entrance of sugar into the 
general circulation, without its having been arrested in the liver and converted 
into glycogen, or upon a diminished destruction of sugar in the blood. There 
are indeed many cases which at first seem only explicable under the former of 
these two hypotheses. The cases alluded to are those in which the sugar dis- 
appears from the urine when the patient restricts himself to a purely animal 
diet, but returns immediately upon any infraction of the rules which have been 
laid down for his guidance. When this happens the amount of sugar voided is 
altogether disproportionate to the amount ingested, and it continues to be ex- 
creted for some time afterwards. In these cases, it would appear, as Dr. Fagge 
well says, as if saccharine food possessed poisonous qualities. If the second 
theory were correct, the excretion of sugar would be uniform throughout the 
day and uninfluenced by food, which we know is not the case. Although 
glycosuria in animals may be produced by puncturing the floor of the fourth 
ventricle. Dr. Fagge is not inclined to look upon diabetes as dependent upon 
a nervous lesion. The operation by irritating the rootlets of the vagi, inhibits 
the vaso-motor nerves of the liver, and hence causes an increased flow of blood 
through that organ, the result of which is a conversion of glycogen into sugar 
beyond the requirements of the system, but it would appear that there is no 
increased production of glycogen, since a few hours after the operation sugar 
again disappears from the urine. 

We have space to call attention briefly to only a few more points in this 
interesting paper. Dr. Fagge believes that simple chronic peritonitis is far 
from being a rare disease, since in the hospital there is on an average one case 
of this kind to two of ascites from cirrhosis of the liver. He has met with 
albuminuria more frequently as a complication of perihepatitis than of cirrhosis 
of the liver — a point which may be of service to us in diagnosis. He regards 
tubercular peritonitis as a curable disease ; the best treatment for it being the 
use of linimentum hydrargyri. 

Dr. Walter Moxon and Dr. James F. Goodiiart publish a series of Ohser- 
vations on the Presence of Bacteria in the Blood and Inflammatory Products 
of Septic Fever, and on the " Cidtivafion" of Septiccemia, which are accom- 
panied by a very full discussion of the whole subject. In the course of 
this discussion the authors take occasion to announce their belief that the 
bodies in the blood which have generally been regarded as bacteria are not 
derived from without, but are really the product of changes going on in the 
blood-corpuscles themselves. The microscopical observations of the blood in 
fever, which appear to have been made with such care as to exclude every 
possible source of error, demonstrated that the colourless corpuscles are often 
in excess, that both they and the red corpuscles may, whilst under observation, 
become granular or beaded at the edges, and that the alterations in form of 
both sorts are often very active. The free granules floating in the serum are 
generally in excess, sometimes largely so, sometimes in normal quantity. 
Their size is tolerably uniform and they are often noticed to cluster together, 
and even to assume dumb-bell and beaded string-like forms. They have never 
been observed to show any movement. In the blood withdrawn from the body 
some hours after death, mobile bacteria have been seen in several instances. 
No difference could ever be perceived between the blood taken from the gene- 



1870.] Guy's Hospital Reports. 211 

ral circulation in cases of erysipelas and that obtained from the diseased part. 
The appearances the authors note, have all been seen before in healthy blood 
subjected to various artilicial surroundings. Tliey, however, agree with Max 
Schultzein thinking that these changes occur with greater rapidity in states of 
fevers than in health. "It might perhaps be thought," they go on to say, 
"that to judge from our own description and facts the presence of bacteria 
becomes a mere question of words. There can be very little doubt that some 
of the bodies we call free granules are of the things which others have called 
bacteria. We have refused this term to them because we have seen no other 
form but the spheroid and its compounds, and because similar bodies, or bodies 
that we cannot distinguish from them, may often be seen in healthy blood. But 
more than tliis, in their hazy outline and- general appearance they are very 
different from those found in the products of inflammation seen in other cases, 
and from those found in decomposing liquids, such as stale urine, etc." 

"^rhe paper is illustrated by a wood-cut which gives the microscopical appear- 
ances of the blood of a man suffering from cellulitis around the knee. 

Dr. A. L. GAt>i.ABiN contributes a long article On the Interprctaiion of Car- 
diographic Tracings and the evidence ivhich tliey afford as to the Causation 
of the Murmurs attendant upon Mitral Stenoses, which is illustrated by a large 
number of tracings. We are not among those who believe that the cardiograph 
is an instrument which is likely to find its way into the hands of the profession 
generally, and we shall, therefore, notice this paper rather briefly. 'I'he author 
holds, as the result of his observations with this instrument — 

" that two totally distinct murmurs maybe caused by mitral contraction. 1st. 
the auricular systolic bruit, which may cither run up to the first sound or be 
separated from it by a short interval ; and 2d, a diastolic bruit due to the venous 
flow through the narrow and roughened orifice, which in rare cases may be- blow- 
ing in quality, and separated from the succeeding systole by a long pause; and 
3d, these two may be merged together into a compound murmur, somewhat 
rough from its commencement, but much intensified in loudness and harshness 
towards its conclusion." 

Clinical Cases of Brain Disease is the title of a second communication from 
Dr. Habeksuon. In the first case a sero-cyst an inch and a half in diameter 
was found directly in the middle of the cerebellum, extending from above down- 
wards through the whole substance of that organ. The patient, a married 
woman of 23, first suffered from severe headache^ the pain being principally 
referred to the forehead, and from giddiness. About four months later vomiting 
came on. This was a distressing symptom, occurring from eight to ten times 
a day ; sometimes small quantities of blood being ejected. Later she had in- 
tolerance of light and sound with some dimness of vision. When she came 
under Dr. Habershon's care she had lost power to some extent in the muscles 
of the arras and legs, but this he ascribed to wasting. There was no paralysis 
of the muscles of the face, or of the muscles of the eye, but later strabismus 
occurred in consequence of paralysis of the external rectus of the left eye. A 
short time before death she became entirely deaf and blind. In addition to 
these symptoms she had several fits, during one of which she died. Dr. Pye- 
Smith, who made the microscopical examination of the cyst, reported that it 
was neither parasitic, inflammatory, nor the result of degeneration of a new 
growth. It was sufficiently large to exert considerable pressure on the sur- 
rounding structures, and in this way the origins of the pneumogastrics, the 
optic and auditory nerves were atfecled, but no degenerative changes had re- 
sulted. In the second case, the prominent symptoms in the order of their 
appearance were as follows : Paralysis of the right side of the face, loss of 



212 Bibliographical Notices. [Jan. 

power of mastication on left side, gradual loss of hearing in right ear, which 
was preceded by subjective sounds, like the noise made by a waterfall ; pain in 
right leg, together with redness and swelling ; pain in head, both in frontal and 
occipital regions; dribbling of saliva, in consequence of depression of right 
side of mouth, insensibility of left conjunctiva, and diminution of sensibility on 
the whole of left side of face, especially on forehead; inability to distinguish 
between sugar and salt on either side of the tongue ; stammering, dulness of 
intellect, and towards the close paralysis of the external recti, vomiting, irregu- 
lar movements, loss of hearing on both sides, dyspnoea, and cough. After death 
a tuberculous mass, said to be as large as two Barcelona nuts glued together, 
was found imbedded in the left half of the pons. The attachments of the left 
fifth and seventh nerves were carried far outwards beyond their natural posi- 
tion in consequence of the expansion of the pons by this mass. In addition 
to the masses in the cerebellum there were a few tubercles in the pia mater ; 
the arachnoid was in a state of inflammatory congestion. 

The patient in Case .3 was a young married woman of 20, who, when 
eight years old, fell on her head, and who had been brutally treated by her hus- 
band. About three months before her death she complained of violent pain in 
her head, which was followed in a month's time by loss of sight. The ophthal- 
moscope showed that both optic disks were ill-defined, congested, and pre- 
sented small hemorrhages near the circumference. At the outer side of the 
optic disk were brilliant white spots, resembling those seen in albuminuric 
retinitis. Insensibility preceded death by some days. The tumour was a large 
one, occupying all the posterior part of the right hemisphere of the cerebrum, 
but not touching the surface at any point. Under the microscope round 
cells, spindle cells, many compound granule cells, and cholesterine crystals were 
found. Dr. Habershon believed the growth in this case to be of an inflamma- 
tory kind, there being no proof of syphilitic disease. 

The principal pathological lesions in the remaining case, which was one of 
Glosso-laryugeal Paralysis, are thus described by Dr. Habershon. 

" There was a small patch of softening just above the right corpus olivare ; the 
floor of the fourth ventricle was deejt in colour, its lateral angles, and the valve of 
Vieussens were softened, and there was a minute patch of the same change in the 
structure of the cerebellum beneath; the right hypoglossal was smaller than 
the left, and in the cervical spinal cord the right anterior horn was softened ; 
still in these parts Dr. Goodhart could detect no strictly morbid changes, and 
no compound granule-cells. The parts especially afl"ected were the origins of 
the hypoglossal and of the facial nerves, those of the spmal accessory and 
pueumogastric less decidedly, and the changes were not of an inflammatory 
character; there was no evidence of thrombosis of the smaller vessels, nor of 
syphilitic disease. The changes at the origins of the spinal accessory and 
hypoglossal nerves were less marked than those described by 'I'rousseau." 

Dr. W. MoxoN contributes the histories of Eight Cases of Insular iSderosis 
of the Brain and Spinal Curd ; and the results of the post-mortem examina- 
tion in two of them, to the literature of this curious affection. As our readers 
are probably aware, this disease has been very fully described, among others, by 
Charcot under the name of Sdarose en 'plaques disshnindes, and by German 
writers as Jiiselforviigc Sclerose, and consists, as the names given to it imply, in 
the dissemination tliroughout the brain and spinal cord, of spherical, rounded, 
or oval patches of a gray material, which is considerably harder than the rest 
of the brain substance, although that substance is itself harder than normal. 
These patches are so evidently distributed indifferently to the structural com 
position of the nervous mass, that it is not surprising that we should have the 
disease presenting a great variety of symptoms, these depending of course upon 



1870.] Guy's Hospital Reports. 213 

the part of the nervous centres principully involved. There are some symp- 
toms which are so usually found, that they may be considered to be diagnostic. 
Firstaraong these is " a peculiar trembling of the head and limbs during move- 
ments, ceasing when the parts are supported." This will alone enable us often 
to distinguish this disease from others in which the tremblings are observed. 
The patient when at rest in bed gives no sign of his malady, but on attempting 
to rise, if the hands are extended to grasp some object for help, they oscil- 
late with a quickish waving, or wagging movement. Charcot has dwelt espe- 
cially upon the rhythmical character of these oscillations. The author alludes 
to this without apparently attaching as much importance to it. A second 
character is " Paralytic weakness of the extremities without numbne.^s." 3. 
Rigidity or contractions of the lower extremities. These contractions are 
sometimes so painful that the aid of the nurse is sought to straighten the affected 
limb. 4. Nystagmus, or twitching of the eyeball, 5. Little disturbance of 
power over excretions. 6. Normal electro-irritability. 7. A peculiar affection 
of the speech, so that syllables are uttered with morbid distinctness of accent. 
This has been thought by some observers to resemble the efforts of a child to 
read out of its primer ; by others the patients are said to scan their words. 8. 
Ultimate impairment of the intellect, and loss of control over the emotions, 
with morbid delusions or morbid moral alteration. The impulses are beyond 
the control of the patient, who laughs and cries readily and without sufficient 
cause. Insular sclerosis maybe divided into three forms, viz., cerebral, si)inal, 
and cerebro-spinal. 

The macroscopic and microscopic appearances presented by the disease are 
very clearly figured in two plates, one showing a section of the brain, the other 
a section of the spinal cord as seen under a one-fifth objective. In the latter 
"the advance of the morbid change is seen in the rise of nucleated tissue 
between the several nervous fibrils, in continuity with the medullary ray or 
with the mass of already existing disease; passing on, the incipient stage similarly 
invades fresh ground, while the previously affected fibres, thus included deeper 
in the change, lose utterly their medullary matter, and at last their axis-cylinder; 
the nucleated substance becoming more and more fibrous. But it is important 
and interesting to notice how deep within this fibrous substance the axis-cylin- 
der may be still distinguished." The practised eye can distinguish in the new 
fibrous substance the round nuclei of " granule-cells" from the elongated nuclei 
of the fibrous substance itself; this fibrous substance represents the thickened 
neurilemma. Amyloid corpuscles are also to be seen. 

In an article On Pulsation of the Liver, Dr. Frederick Taylor calls atten- 
tion to a symptom which he says is of frequent occurrence in tricuspid regurgi- 
tation, and the importance of which in a diagnostic point of view has been very 
generally overlooked by writers. Pulsation of the liver depends of course upon 
regurgitation through the tricuspid orifice and into the cava descendens and 
hepatic veins, and can be very readily distinguished from other forms of pulsa- 
tions in the abdomen by the following characters. 1st. The extensive area 
over which pulsations can be felt, namely, from near the left costal cartilages 
to the right lumbar region, and secondly, the exact correspondence of this pul- 
sation to the surface of the enlarged liver. Dr. Taylor says, the pulsation is 
most readily felt when one hand is placed near the umbilicus and a little to its 
left, and the other on the right side of the abdomen in the axillary line. But 
the same expansion will be perceived when one hand is placed on the left lobe 
of the liver three inches to the left of the umbilicus and just under the left 
costal cartilages, while the other is placed under the lip of the right twelfth 
vib. In this last region pulsation can be felt within three inches of the line of 



214 Bibliographical Notices. [Jan. 

the spinous processes. The paper contains the reports of four cases in which 
hepatic pulsation was observed, and a reference to another case, and is illus- 
trated by sphygmographic tracings of the movements of the abdomen in two 
of these cases. 

Dr. Paul Henry Stokoe contributes some Practical Rtmarls on the Causes 
and Treatment of some common Forms of Vomiting, which is a well written 
essay on this subject, but we do not find that it contains any suggestions which 
would be new to most of our readers. 

Appended to the volume are the usual statistical tables. From these we 
learn that the total number of patients resident in the hospital during the year 
1874, amounted to 5776, being 205 in excess of the previous year. Notwith- 
standing this large number, the accommodation utilized fails to represent fairly 
the actual resources of the hospital ; for at no time were more than 600 of its 
TOO beds occupied. Of the 594 deaths reported in 1874, 102 were caused by 
accident. The number of out-patients treated in the course of the year 
amounted to 85,090. 

The volume is a fairly representative one of the value of the series. — A few 
of the papers are not so thoroughly practical in their character as we like to 
see in a volume of Hospital Reports, but this criticism is by no means appli- 
cable to them as a whole. 



Art. XXI. — A Manual of Diet in Health and Disease. By Thomas King 
Chambers, M.D. Oxon., F.R.C.P. Lond., Honorary Physician to H. R. H. 
the Prince of "Wales, etc. etc. 8vo. pp. 310. Philadelphia : H. C. Lea, 
1875. 

The literature of Diet, like that of other subjects connected with hygiene, 
is now rapidly increasing. Even ten years ago, hardly more than two or three 
treatises upon it, having any claim to a scientific character, existed in the 
English language. Now we have had, within a short time, Letheby, Edward 
Smith, and Pavy, besides the very original and remarkable treatise of Dr. 
Anstie on Stimulants and Narcotics, and the popular work of Dr. Beard upon 
the same subject. While less elaborate and systematic than some others. Dr. 
Chambers' book seems to us the most suggestive of them all. In his preface 
he announces that, as his aims in this handbook are purely practical, he has 
not thought it right to increase its size by the addition of the chemical, botan- 
ical, and industrial learning which rapidly collects around the subject of diet. 
Space has thus been gained for a full discussion of many matters connecting 
food and drink with the daily current of social life ; the manner of considera- 
tion of which is the leading peculiarity of this book. 

Dr. Chambers divides his work into three parts— taking up in succession 
General Dietetics, Special Dietetics of Health, and Dietetics in Sickness. 
First, in consideration of theories of Dietetics, he asserts, on the basis of com- 
parative anatomy, that to judge by form and structure alone, the natural food 
of an adult man must be pronounced to be nothing. On the other hand, if we 
read the laws of man's nature by the light of the general consent of the individ- 
uals of his race, we shall arrive at the conclusion that his food is everything 
which any warm-blooded animal can use as nourishment. The power, however, 
by which man becomes truly omnivorous is habit. Man's chief bodily strength 
depends on his willingness to submit to the pain of acquiring habits, and on 



1810.] CiiAMDERS, Manual of Diet in Health and Disease. 215 

Ills forcing his domestic stock to submit to it, for the sake of a future advan- 
tage. 

The physiolocry of digestion, and the leading chemical facts which hear on 
the subject of nutrition, are dwelt upon succinctly in our author's first, fourth, 
and fifth chapters. The e.xperiments and calculations of E. Smith, Haughton, 
Frankland, and others are brought to view, in order to determine the amount 
and character of food required to meet the outgoings resulting from the waste 
of tissue and the production of force in the body. It is obvious that the food 
which supplies most accurately the demand for carbon and nilrugen will be 
the most economical. A diet which makes it necessary to eat too much carbon 
in order to secure a due amount of nitrogen, will involve waste, and must bur- 
den the digestive viscera with a useless load ; and a similar reckoning applies 
to the lime, sulphur, phosphorus, hydrogen, and oxygen which are required in 
the body. For example, milk, which is suitable to the young animal, whose 
main duty is growth, is not a typical diet for adults, because its nitrogenous 
matter is in considerable excess in proportion to the carbonaceous. An average 
adult may consider that he is taking enough to satisfy the ordinary require- 
ments of healthy activity, if he eats in twenty-four hours the equivalents of a 
pound of meat and two pounds of bread. Age, labour, idiosyncrasies, and con- 
ditions varying from health, make important differences in this demand. 

Chapter II., a long one — nearly sixty pages — is on the Choice of Food ; Chap- 
ter III., more brief, on the Preparation of Food. Dr. Chambers gives a mul- 
titude of valuable practical facts and hints, comprising just what everybody 
wants to know, under the following heads: Butcher's Meat; Poultry and 
Game; Fish; Garden Produce; Fruit; Groceries, etc.; Dairy Produce; 
Bread Stuffs; Alcoholic Drinks ; Waters. We miss the discussion, which 
precedents in other works had led us to expect, upon the hygienic relations of 
tea and coffee. Upon the former, besides a recommendation (p. 120) that tea 
should not be taken in the afternoon, these brief sentences are almost all that 
is said : " The uses of tea are — 

" 1st. To give an agreeable flavour to warm water required as a drink. 

" 2d. To soothe the nervous system when it is in an uncomfortable state 
from hunger, fatigue, or mental excitement." (p. 53.) 

No opinion is expressed as to the comparative wholesomeness of tea and 
coffee as daily beverages : and no allusion is made to the injury which excessive 
consumption of either, but especially of the latter, produces in many persons. 
Nor does the author refer at all to the interesting (indeed, important) question, 
as to the influence of coffee and tea respectively on tissue-metamorphosis. We 
are loath to give up the idea, long ago suggested by Lehmann, that coffee at 
least, if not tea, when given under circumstances of deficiency of food or excess 
of work, may economize the resources of the body, by retarding waste, and 
making the supply of nutriment go further in proportion to the wear and tear 
of the system. If it be worth while, moreover, to advise against tea in the 
afternoon because of its diluting the gastric juice overmuch, it might seem 
equally appropriate to caution those in whom coffee produces palpitation of 
the heart, wakefulness, or nervous dyspepsia, against indulging freely, if at all, 
in that delightful beverage. 

No subject of more practical interest and consequence is treated of in this 
work, than that of the relations of alcohol to health ; and to none has the 
author given more space. His consideration of it is, however, somewhat un- 
systematic ; we have to search for it in at least half a dozen places in the vol- 
ume. Our endeavor will be to present briefly the main points brought out 



216 Bibliographical Notices. [Jan. 

upon this, at present the most warmly controverted of all topics in personal 
hygiene. Let us cite his first paragraphs upon wine : — 

" This is a subject terribly overladen with literature, historical, poetical, in- 
dustrial, scientiDc, and occasionally nonsensical. So that a simple purchaser 
who wants to Unow how to get a good wholesome glass of wine, has no small 
difficulty in winnowing out the required information from so much chaff. 

" The first thing a householder should think of before he stocks his cellar, 
is, what he wants wine for. Is it to take as a regular beverage, or on festive 
occasions only ? Does he intend to employ it for himself or others as a medi- 
cine, or to drink it only because it is nice ? Here are the four chief uses of 
wine, and different wines are suitable for each. 

" As a regular beverage for a healthy person, there is no wine in the English 
market equal to claret." (p. 72.) 

Dr. Chambers would thus seem ready to accept Dr. Anstie's opinion, that 
some amount of alcohol, " as a regular beverage," is good for a healthy person. 
On another page (p. 107) he says : — 

" It is possible to imagine a state of society, as among the Pitcairn Islanders, 
for example, where everybody was apparently the better for taking no alcohol 
in any form, but even in that instance, the abstinence does not seem to have 
lengthened life, and it is certain that in Europe it would shorten it for many 
of our most active and useful citizens." 

Later in the book it is said (p. 137) that up to the period of puberty the daily 
use of wine should be allowed only during illness and by the e.xpress advice of 
a medical man. This restriction, however, does not, with him, exclude " occa- 
sional festivities." 

We are told (p. 80) that " almost all the cases in which injury to physical 
health has been traced to alcohol, are in reality due to spirit-drinking." Cer- 
tainly this is an erroneous statement. "What physician has not met with a 
number of instances even of delirium tremens, to say nothing of gout, disease 
of the kidneys, etc., from wine and beer drinking ? Dr. Chambers, indeed, 
afterwards admits this ; saying (p. 219) that " the whole evil of drinking does 
not arise out of fusel oil ; for we see the consumers of the very soundest beer 
and wine often suffer." Sir Henry Thompson's evidence on this point is of 
great importance. In his letter not long since addressed to the Archbishop 
of Canterbury, he writes thus : — 

" I have no hesitation in attributing a very large proportion of some of the 
most painful and dangerous maladies which come under my notice, as well as 
those which every man has to treat, to the ordinary and daily use of fermented 
drink taken in the quantity which is conventionally deemed moderate. . . . 
There is no single habit in this country which so much tends to deteriorate 
the qualities of the race, and so much disqualifies it for endurance in that com- 
petition which in the nature of things must exist, and in which struggle the 
prize of superiority must fall to the best and the strongest." 

Dr. Parkes' well-known experiments upon the physiological action of alco- 
hol would justify a stronger statement, to a similar effect, than he has ventured 
upon ; and Dr. B. W. Richardson, in his Cantor Lectures, illustrates the sort 
of discovery men are now making with the light of science thrown upon social 
experience, by comparing it to the strong impression which would be made 
upon the public mind, " if, after some long period in which the boilers of 
steam-engines had been fed with a mixture of spirit and water, it was suddenly 
discovered that the engines would work quite as well with the water without 
the spirit, and that the millions of pounds that had been devoted to the pro- 
duction of the spirit had been so much unnecessary waste." 

We believe that there is much importance in recognizing it as a hygienic 
principle, that alcohol in never necessary or likely (o be beneficial to persons in 



1876.] CiiAMUEHS, Manual of Diet in Health and Disease. 217 

perfect health. If this be trraiifeil, then tliose who still wish to take it '• because 
it is nice," or because they like its immediate effects upon them, may do so 
with their eyes open to the risk and responsibility. Also, the same principle 
leaves ground for the acceptance of all that experience proves concerning the 
utility of alcohol in various conditions of debility, sometimes with and some- 
times without other symptoms of positive disease. Dr. Chambers gives, in the 
work before us, an admirable analysis of the moduR operandi of alcohol in 
lessening the friction of life, with those who are constantly worried or over- 
worked, lie calls it an aiiceslhed'c ; "'curbing the deleterious consecpience of 
excessive energy of the nervous system." There may be something deceptive in 
this, as was shown by Dr. Richardson, in his experiments upon animals exposed 
to cold. It is well known that persons drinking spirit/ee/ cold less than others ; 
yet Richardson found that of two animals subjected to the same reduced tem- 
perature, one placed under the influence of spirit died, and the other, without 
it. survived. Still, there is much experience showing that the mild '■ aniesthetic" 
effect of alcohol is sometimes of value. To secure this advantage, how much 
depends upon dosage ! A little may do good, when large imbibition would do 
great mischief. This is commonly not well understood. Hygienic doses of 
spirits (seldom so available, however), of wine, or even of beer, ought to be 
much smaller than convivial draughts. Yet we doubt whether these have not, 
in past times, been too large for real enjoyment. Epicurus was too wise to 
seek for happiness in actual intoxication; nor do we believe that Anacreou 
wrote his immortal songs under the inspiration of more than moderate pota- 
tions. Even Dr. Anstie was careful to assert that " alcohol was never designed 
by the wisdom of Providence to be employed by the human race as an anies- 
thetic at all," but for the sake of the stimulant qualities of its non-narcotic 
doses. Dr. Chambers does not, according to our judgment, lay down clearly 
enough the signs by which the limits of safely in the use of alcohol, in any case, 
are marked. When it hurries the pulse, flushes the face, or is in any degree 
" felt in the head," the line of hygienic action must have been over-past. 
Moreover, it is from excess, always, not from any intrinsic tendency under all 
circumstances to invite inebriation, that we find growing that slavery to alcohol 
which makes intemperance a curse. If this were not the case, the administra- 
tion of alcohol as a medicine might indeed be open to the doubts which ex- 
tremists urge against it. But the experience of thousands of cases under the 
observation of physicians shows that, with skill in its adaptation to the condi- 
tions of disease, with its quantity, frequency, and period of continuance all 
rightly limited, it may be and is constantly used without the slightest degree 
of promotion of morbid craving for it. 

We are at a loss to comprehend by what sort of experience Dr. Chambers 
can have been led to understate (as he does) the frequency, if not the reality, 
of methoniania. He says (p. 228) : — 

"There may possibly be some rare cases of true 'dipsomania;' where, with- 
out any other mental disease, the patients are carried off by an uncontrollable 
impulse to drink; but they certainly are very rare indeed, and every alleged 
instance that I have investigated has always exhibited also some other form of 
insanity, sufiBcient to justify the imposition of restraint, or else proved to be 
using the cant of the day as an excuse for selfindulgence. The exceptional 
cases may be separately dealt with, when they occur ; but as a rule I think it 
is better to give men the education of being their own gaolers than to let them 
lean on the weak crutch of state inebriate asylums." 

We must dissent strongly from this opinion. What number of drunkards 
can be trusted to be " their own gaolers ?" Such an opinion seems to us equally 



218 Bibliographical Notices. [Jan. 

far from the truth with that of one or two American writers, who have asserted 
that no one ever becomes hopelessly intemperate unless yJrs^ insane, the dispo- 
sition to drink to excess bein^ his monomania. The results of treatment in 
inebriate retreats, at Boston, Binghamton, Media, and Philadelphia, have 
proved that, in seclusion, recovery from intemperance is made possible in cases 
many of which had been, and no doubt would have continued to be, incurable 
without it. 

Dr. Chambers would advise the discouragement of intemperance, as a vice, 
by social disgrace rather than by legal penalties. He has no faith in " prohi- 
bition." He commends the cheapening of fermented drinks, such as beer and 
wine, by "fiscal regulations," the burden of taxation being laid on the retail 
trade in spirits. Citation is made (p. 227, note) of the evidence of Mr. James 
Morrison, to the effect that drunkenness has been made much less common in 
California than it was twenty years ago, by the introduction of native wines, 
supplanting stronger liquors. This is highly important, if exactly true. It is 
desirable that confirmation or disproof of it should be made known, by those 
having opportunity for the observation required. 

Without quoting much recent science regarding alcohol, Dr. Chambers has 
contributed to it some interesting and very carefully analyzed experiments of 
his own. From these he infers that alcohol given in divided doses tends to 
diminish the metamorphosis of material in the body ; especially reducing the 
amount of phosphates eliminated in the urine. He regards it as helpful to the 
aged, and to brain-workers ; but never before exertion, or even during active 
mental exercise ; always at its close. In hysteria he would especially prohibit 
it. Surely this conclusion must have not a few exceptions ; unfavourable effects 
upon hysterical subjects may, perhaps, find their explanation mostly in errors 
of quantity. 

There is evident wisdom in the following admonitory language : — 

" One of the most telling questions that can be asked of a life proposed for 
insurance is, ' Do you ever take spirituous liquors in the forenoon ?' If the 
answer is in the affirmative, an immediate rejection is the only safe course for 
the office. As to small quantities of beer or wine that are consumed between 

breakfast and the midday meal to the shame of our profession, it 

must be confessed that many of us have erred most unhappily by recommend- 
ing, or sanctioning the habit in weakly or self-indulgent women. The weaker 
they are in body or mind, and the more hysterical, the more reason there is for 
withstanding the temptation. "We must be proof against tears and sighs, 
blandishments, entreaties, and reproaches, or we are not fit to bear the rod of 
J^^sculapius." (p. 206.) 

Our author gives only a short passing notice to tobacco. He advises against 
it during working hours; but says that, "as a relaxation afterwards it is, in 
moderation, beneficial." What, however, is moderation? This appears to be 
left to the user. 

We have dwelt so long upon what have appeared to us the most debatable, 
as well as the most interesting, portions of Dr. Chambers' book, that we can 
scarcely do more than enumerate the topics further considered by him. Under 
the heading of '-Special Dietetics of Health," he discusses, in ten chapters, 
the Regimen of Infancy and Motherhood, of Childhood and Youth, of Com- 
mercial, Literary, and Professional Life, Noxious 'J'rades, Athletic Training, 
Hints for Healthy Travellers, Effects of Climate, Starvation, Poverty and 
Fasting, and the Decline of Life. Part III. embraces, under the general title 
of " Dietetics in Sickness," the study of the Diet and Regimen of Acute 
Fevers, that of other Inflammatory States, of Weak Digestion, Gout, Rheu- 
matism, Gravel, Stone, Albuminuria and Diabetes, Deficient Evacuation, Neive 



187G.] Seitz, Tubercular Moiiingitis of Adults. 219 

Disorders, Scrofula, Rickets, Consumption, and Disease of tbe Heart and 
Arteries. 

We have spread this bill of fare somewhat fully before our readers, so 
that they may judge how impossible it must be for a reviewer to make a pot 
poiii-ri of such solid and substantial materials. Moreover, we hope that many 
will be induced, for their own advanta{i:e, to read and digest the whole work. 
Though not always infallible, they will find in it much information, available 
not only in personal hygiene, but also in the treatment of patients ; valuable, we 
believe, in equal degree with that which concerns the most serviceable agents 
of the materia medica. 11. II. 



Art. XXII. — Die MevingHiH Tuberculosa der Enoachsenen, Klinisch Bcar- 
beitet. Von Dr. Johannes Skitz, Privatdocent an der Universitat Zurich. 
8vo. s. 388. Berlin : August Hirschwald, 1874. 

The Tubercular Meningitis of Adults. Clinically studied by Dr. Johannks 
Seitz, etc. etc. 

"Wk have been so much accustomed to regard tubercular meningitis as a 
disease almost exclusively of infancy and childhood, that it was with some 
surprise we found upon opening Dr. Seitz's admirable clinical essay that he 
had been able to collect 1.30 cases of the disease, 51 of which were treated by 
Biermer and Griesinger at the Zurich clinic, during the period of time between 
the end of April, 18G0, and the end of August, 1871, or very little more than 
eleven years. The number is so large, and the time so short, that, as it is 
impossible to doubt the fairness with which the author has pursued his investi- 
gations, we can only conclude that the disease is more prevalent among adults 
in Switzerland than elsewhere. In a connection with a large general hospital, 
extending almost continuously over nearly twenty years, only one case of 
tubercular meningitis has come under our immediate care, in which the patient 
was more than fifteen years old. This experience may be, it is true, ex- 
ceptional, but we know it is not isolated. Certainly Zurich is the only place, 
of which we have heard, in which " 15 deaths out of every 1000 occurring in 
adults is caused by tubercular meningitis." 

The book contains, in more or less detail, the histories of 67 cases. These, 
we need not say, make it very valuable as a work of reference, the more so as 
we know of no other book in which the subject is so fully discussed. The 
author, moreover, subjects the 130 cases to a full analysis, the results of which 
are so interesting that we regret that the space at our command does not 
permit us to follow him so closely through the various steps of this process 
as we should like. Our notice of the book must, therefore, notwithstanding its 
importance, be brief. 

Men would appear to be much more liable to this disease than women, for of 
the whole number of cases, 97 occurred in males, and only 33 in females ; but 
the author thinks, and probably correctly, that these figures do not fairly 
represent the proportion of the two sexes affected, inasmuch as the number of 
men in a general hospital is always larger than that of the women. The cases 
as regards the age of the patients were distributed as follows ; 28 between 16 
and 20 years ; 29 between 21 and 25 ; 26 between 26 and 30 ; 14 between 31 
and 35 ; 13 between 36 and 40 ; 11 between 41 and 45 ; and 8 between 46 and 
60. The author refers in another part of his book to a patient whose age was 
63, although he gives no details of this case. In twenty cases in which the 



220 Bibliographical Notices. [Jan. 

spinal canal was opened, the spinal meninges were found to be the seat of 
tubercular deposit in twelve, and to be perfectly healthy in eight. The cases 
in which the examination was made were chiefly, if not exclusively, those in 
which spinal symptoms had presented themselves during life, and, therefore, 
tubercular deposit in the spinal meninges is probably not of very frequent 
occurrence in the adult. Hereditary predisposition to tuberculosis was wanting 
in one-fourth of the whole number of cases ; it was distinctly made out in another 
fourth, and there was good reason to believe that it existed in a large propor- 
tion of the other half. Among the exciting causes of tubercular meningitis in 
children, scarlet fever, measles, typhoid fever, retroceded eruptions, emotional 
disturbances, injuries, heat and cold, excesses, and mental and bodily fatigue 
have always been thought to play a prominent part, but in 117 of his cases the 
author was unable to find that any of these causes had had the slightest influ- 
ence in the production of the disease. In fact, in a large proportion of cases, 
the patient appears to have been stricken down by the disease when he was 
apparently in good health. We say apparently, because in " by far the majority 
of cases, miliary tubercle was found in bodies in which cheesy masses were also 
present." In the cases observed at the Zurich clinic, there was not a single 
one in which there was not some evidence of the previous existence of chronic 
inflammation, and this is true of 93..5 per cent, of the other cases. In some 
cases, however, nothing more was found than an inconsiderable induration of 
the lungs, or a chalky deposit in them. While admitting, therefore, that there 
is a connection between caseous degeneration and miliary tuberculosis, the 
author thinks that it is not yet proved that the latter is the result of the 
absorption of the products of the former, holding that the two conditions arise 
from the same cause, and that both are met with in individuals in whom there 
is a predisposition to the occurrence of inflammatory exudations, which contain 
an unusual number of cells, and which are remarkably prone to undergo 
caseous degeneration. This is much the same view as that at present taught 
by Rindfleisch,' and has in its favour the fact that in certain animals an erup- 
tion of tubercles is produced not merely by the insertion under their skins of 
caseous matter, but also by the application of any irritant which is capable of 
exciting free suppuration. The peculiarity appears, therefore, to lie in the 
individual rather than in the irritant applied. We have not the time to go 
fully into the question, which is one of great interest to us, and will only call 
attention to the fact that in a large proportion of Dr. Seitz's cases caseous 
degeneration of some organ apparently preceded the occurrence of tubercular 
meningitis — a fact which he admits. 

A very long chapter is devoted to a description of the symptoms presented 
by tubercular meningitis when it occurs in the adult. We cannot find from 
what Dr. Seitz says, that they differ from those which characterize the disease 
in infants and children. We have the same intense headache, the same mental 
disturbance, the same increased sensibility of the skin, wliich renders the 
lightest touch or the slightest movement painful, the same retraction of the 
head, and obstinate constipation and vomiting, and, in the latter stages of the 
disease, the same paralysis, stupour, and convulsions. The thermometer was 
used daily in a number of the cases with the result of showing that the fever 
ran a much less regular course than in pneumonia, typhoid fever, or septi- 
caemia. It was nevertheless remarkable that in many cases the approach of 
death seemed to influence the temperature, in some instances raising it very 
abruptly, in others depressing it much below that of health. In the tubercular 



' Ziemsseu's Cyclopsedia of Mediciue, vol. v. 



18Y6.] Report on the rublic Ilcnlth. 221 

meningitis of the young, the pulse has been observed to be frequent at the 
beginning of the ilisease, slow in the midtlle, and again frequent at the end. 
This peculiarity has not been recorded in Dr. Seitz's cases. 

The ophthalmoscope was used in a certain number of the cases treated by 
Biermier and Griesinger. In eight of them the eyeground was found entirely 
free from pathological changes, no tubercles, no neuritis, and no congestion of 
the veins being found. In si.\ other cases all was normal except the vessels. 
Four times only were decided changes found. These consisted, in one case, in 
a declining neuritis, in two cases in a moderate degree of choking of the disk, 
and in the fourth in retinitis. Tubercles of the choroid were not detected in 
any of them. 

The diagnosis of the disease seems to be attended with some difficulty, for 
in some instances its real nature was first discovered upon the post-mortem 
table. Among the conditions which have been mistaken for tubercular menin- 
gitis are Bright's disease, acute lead-poisoning with cerebral symptoms, typhoid 
fever, septicemia, hysteria, mania, cerebral syphilis, and simple inflammation. 

The disease ended fatally in all the I'M cases, and while Dr. Seitz does not 
deny the possibility of recovery, he has never met with the report of a case in 
which this is said to have occurred, which seems to him at all convincing. 
Unfortunately, the author, who has added by this monograph so much to onr 
knowledge of the disease in every other respect, can give us but few hints as 
to its proper treatment. This, as he believes the disease to be incurable, should 
be addressed to the symptoms. Among the most distressing of tliese is pain, 
which may sometimes be relieved by the abstraction of a moderate amount of 
blood, and by the use of anodynes. J. H. H. 



Art. XXJll. —Pahlic Uealfh. Repnrt<i of the Medical Officer of the Privy 
Council and Lncal Gavernmenl Board. New Series. No. II. Sopplcmen- 
tari/ Report to the Local Goiernmevl Board on fome 7-eceiit Inquiries under 
the Public Health Act, 1858. Presented to both Houses of Parliament by 
command of Her Majesty. Pamphlet, pp. 286. London : Printed by George 
E. Eyre and ^ViIliam Spottiswoode, 1874. 

TiiK injury which preventable diseases inflict upon a community cannot be 
measured solely by the mortality they cause, great as this undoubtedly often- 
times is. It would be unfair to leave out of consideration the physical suffer- 
ing and disablement which they occasion, the sorrows and anxieties, the often 
permanent darkening of life, the straitened means of subsistence, the very fre- 
quent destitution and pauperism which attend or follow them. Of these, as Dr. 
Simon remarks in the opening paper of the volume, death-statistics testify only in 
sample or suggestion. Among preventable diseases enteric fever occupies, it is 
generally conceded by physicians, a prominent position, but it is still nevertheless 
the fact that the means by which it may be avoided are either wholly unknown 
to the great mass of people, or wilfully disregarded by them. We have, there- 
fore, little doubt that the dissemination of the kind of knowledge contained in 
this volume will be productive of a vast amount of good. But professional 
readers will also find much to interest them, and especially in the five reports on 
outbreaks of typhoid fever in different parts of England, written by Drs. Buch- 
anan. Blaxall, Ballard, and Radclitfe. Two of these outbreaks were traced to 
contamination of drinking water by sewer-gases; in the other three, milk was 
the medium of contagion. 



222 Bibliographical Notices. [Jan. 

Our readers are probably aware that many years ago a fever whicb was called 
typhus, but which was probably typhoid (for at that time the two diseases had 
not been distinguished), was observed to prevail in Edinburgh among the cus- 
tomers of a dairyman, one or more members of whose family were found upon 
investigation to have suffered from the disease. In this instance the man him- 
self was supposed to have carried the infection around with him from door to 
door, and the important part which milk plays in the spread of disease seems to 
have been wholly overlooked. More recently Dr. Bell, of St. Andrews, reported a 
series of cases of scarlatina occurring among the customers of a milkman who 
had allowed a man convalescent from this disease to milk his cows. But it 
was reserved for Dr. Ballard, in a report On a Localized Outbreak of Typhoid 
Fever in Islington in 1872, to show clearly that milk may be the medium by 
which the disease is disseminated. 

The most important of the three outbreaks of enteric fever dependent upon 
contaminated milk occurred in the districts of St. Marylebone, St. George's 
(Hanover Square), and Paddington, which include, we believe, some of the best 
portions of London. Dr. Radcliffe's investigations extended to 244 cases, dis- 
tributed in 143 households ; these cases all occurred during the nine weeks 
ending August 30, 1873, and were, in by far the greater number of instances, 
confined to the households of well-to-do and wealthy people, 26 only happening 
in families not coming within this category. Although suspicion very early fell 
upon the milk supply, as the cause of the epidemic, the medical officer em- 
ployed to conduct the inquiry did not limit his investigations to this alone, but 
examined into the condition of the sewers of that part of the town, and also into 
that of its water supply. The former had recently been put into order, and no 
fault could he discover in them. The latter was derived from the works of two 
companies which in itself made it improbable that it was the source of the dis- 
ease, and, in point of fact, the water when analyzed was found to be perfectly 
pure. The drainage of the houses was in almost every instance excellent. In 
some of the houses, notably in that of Dr. Murchison, the distinguished author 
of the work on Continued Fevers, whose family suffered severely, every pos- 
sible precaution had been taken to render it fever-proof. 

p]arly in the outbreak Dr. Murchison satisfied himself that the only probable 
mode of introduction of the disease into his house was by the milk supply. The 
suspicion having been aroused, he quickly ascertained that almost all of the fami- 
lies which were then affected with enteric fever within his knowledge and that 
of his professional friends, obtained their milk from the same dairy which sup- 
plied his household. This information was communicated to the medical offi- 
cers, and formed the groundwork of the preliminary departmental inquiry. 
Some remarkable discoveries were made in the course of the investigation. 
Thus, 1. Of the 244 cases of enteric fever to which it extended, 218 (that is to say, 
nine-tenths) were in households which consumed milk obtained from a particular 
service of a particular dairy. The proportions of cases thus occurring in house- 
holds using a particular milk supply, rendered it probable that the connection 
between the milk supply and the prevalence of fever was not casual. 2. The 
number of patients with typhoid fever coming from the infected district ad- 
mitted into the hospitals of London during the two months ending September 
1st, was 64; .^2 of whom habitually consumed milk obtained from the particu- 
lar service of the particular dairy previously referred to, and only 12 had not 
at any time consumed milk from this source of milk-supply. 3. With one excep- 
tion, which readily admitted of explanation, wherever the milk of this supply 
was distributed, there the cases of enteric fever which collectively formed the 
outbreak were distributed. Where the milk-supply stopped short, there, as a 



1876.] Report on the Public Health. 223 

rule, no cases occurred. 4. The peculiar limitation of the disease to well-to-do 
and wealthy families to whom the milk-supply was also almost confined. 5. More 
direct evidences of a connection between this milk-supply and the determining 
cause of the outbreak is furnished by the fact that the disease picked out streets 
to which the milk was distributed, and the houses in those streets which re- 
ceived the milk. Of 88 infected streets, this milk-supply went into 77, and of 
132 infected houses in the 77 streets in which fever occurred, 14 only did not 
receive this milk-supply. In 118 houses out of 760 (1.5.5 per cent.) taking 
the milk, there were 218 cases of enteric fever, while in the 14 houses out of 
(in round numbers) 23,000 in the same area not taking the milk, there were 14 
cases only. G. Still more direct evidence to this end is afforded by the disease 
during the outbreak having picked out the members of certain families who 
alone drank the milk " as it came from the dairy," and by the seizure of persons 
who had exceptionally used it. Several instances of both these classes are 
given, but want of space prevents us from reproducing them here. 7. Women 
and children furnished the largest number of cases. Thus, of the 244 cases, 
29 only occur in men, the number of children being 96. Women and children, it 
will be admitted, drink much more milk as a rule than men. Among the male 
patients there were several instances in which the sufferer had been a large 
consumer of milk. 8. An isolated group of cases occurred at the same time in 
another district of the metropolis. Upon inquiry it was found that the families 
in wliom they occurred derived their milk-supply from a branch establishment 
of the dairy, in Soho, the milk of which was suspected to have caused the out- 
break in St. Marylebone. 

At the commencement of the inquiry, observation of the manner in which 
milk was received from the country at the suspected dairy, led to the inference 
that, to explain the then known facts of the outbreak, it was not necessary to 
assume that the milk from more than one of the several farms from which the 
dairy obtained its supplies was infected with enteric fever material. This 
assumption was fully justified by the result of further investigation, which 
showed that the infected milk came from a farm which, in addition to supplying 
somewhat over one-sixth of the ordinary milk supply received by the implicated 
dairy, supplied also the whole of the so-called " nursery milk." This milk, 
although so designated for convenience, was not invariably used for nursery 
purposes. It was retailed at the same price as ordinary milk, and it was de- 
signed to meet the desire of those customers who had an objection to the 
mingled milk of many animals for nursery or other use. Suspicion first fell 
upon the " nursery milk" as being, of the two different binds of milk issued by 
the implicated dairy, that alone which was infected. Fnrther observation fully 
confirmed this suspicion, for in upwards of sixty-three families living in 
Pimlico, and receiving the whole of the ordinary milk coming from the in- 
fected farm, but taking no " nursery milk," not a single case of fever occurred ; 
while, on the other hand, there were numerous instances in which families 
suffered from having some of the latter mixed with their usual supply. In 
fact, it soon became plain that the ordinary milk of the dairy was infected only 
to such extent as "nursery milk" might have become mixed with it. The 
farms from which this milk was derived were visited by the medical officer, who 
found a condition of things which rendered it highly probable that the milk 
had been charged with enteric fever material, and not improbably with the 
excremental discharges of a patient suffering from enteric fever, shortly before 
and during the earlier period of the outbreak in Marylebone. 

On the 8th of June the occupant of the farm died suddenly in' the fourth 
week of an attack of ambulant enteric fever. The discharges from the bowels 



224 BiBLTCGRAPHiCAL XoTiCES. [Jan. 

were, after the nature of the disease had been recognized, buried in an ash 
heap beyond the precincts of the farm building, no disinfectant having been 
mixed with them. On the 12th of August a son of the above patient, aged 12 
years, was seized with enteric fever, and passed through a slight but well- 
marked attack. 

On account of gradually increasing distastefulness, there was reason to sus- 
pect that the dairy well connected with the implicated farm might have become 
polluted with excremental matters. As a consequence, the water from this 
well had not for some time been used for drinking and cooking purposes, for 
which water was obtained from a spring about one-sixth of a mile distant from 
the farm-house. Among the several sources of pollution of the dairy well, it 
is only necessary to particularize one, which was detected as follows : The 
water having been pumped out as low as possible, a well-marked line of soakage 
was observed on one side of the well. By digging a series of trenches, it was 
discovered that the cause of the foulness of the water was soakage from the 
pig-sty. Now close to this was situated the ash heap in which were buried the 
evacuations of the patient who died on the 8th of June. " In other words," to 
use Dr. Radcliffe's own language, "by an unhappy and altogether unforeseen 
chance, and in carrying out precautions to obviate any possibility of mischief, 
the matters from which mischief was most apt to arise were deposited in. per- 
haps, the only spot on the farm premises where they would certainly find their 
way into the water used for dairy purposes." 

The outbreak of the fever in Marylebone began in the week ending July 5; 
consequently its determining cause must have begun to operate some time 
during the week ending June 21. 

" The dropping cases of the first three weeks of the outbreak were followed 
by the great outburst extending over three weeks, and then by a decline, sudden 
at first, but occupying three weeks following. 'I'hese phenomena might not 
unreasonably be held to have reference to the physical phenomena of soakage 
of the infective matters into the well, slowly and in small quantities at first, 
rapidly increasing in amount as the infective matters occupied more fully the 
line of soakage, and as rapidly declining, but still not at once, and wholly 
coming to an end, as those matters became exhausted. Given a fortnight for 
the soakage to begin to affect the water, a not undue period, having regard to 
ibe kind of soil it would have to pass through in a part of its course, the rest 
of the phenomena would consistently explain the outbreak, provided the con- 
taminated water were mingled with the milk."' 

It was, of course, impossible to obtain from the farmer's widow an acknowl- 
edgment that the water from the dairy well had been added to the milk for 
the purpose of diluting it. She admitted that the water had been used for 
cleansing the dairy utensils, and that when used for this purpose it was cold. 
No accidental pollution, however, would explain, as Mr. Radcliffe remarks, 
the limitation of the infection to " nursery milk," or the persistence of this 
infection for a definite time. 

In the other two outbreaks, in which milk was the medium of contagion, the 
water used for dairy purposes was likewise polluted by the discharges of enteric 
fever cases ; and it was ascertained through a boy, who himself fell a victim to 
the fever, that at one of the implicated dairies the infected water had been 
added to the milk. The results of Dr. Ballakd's investigations so closely 
resemble those obtained by Mr. Radcliffe that it would be mere repetition to 
give them in full. Thus the fever picked out the houses supplied by the im- 
plicated dairies, and first attacked in every family those who were the largest 
consumers of milk; while those who drank of it sparingly either escaped en- 
tirely or were affected only towards the close of the epidemic. 



ISTfi.J Transactions of American State Medical Societies. 225 

The reports of the two outbreaks of typhoid fever, due to coulumluation of 
drlDkinjT water by sewer-gases, are also interesting, and we, therefore, regret 
that our notice of them must be a very cursory one. One of these outbreaks 
occurred in Tree Court, Caius (^ollege, Cambridge, and was investigated by Dr. 
Hi'OHANAN, who came to the conclusion that it was caused by the water-pipes 
communicating directly with the water-closets without the intervention of a 
service cistern. It was clearly shown that if, while the water-supply of that 
part of the college was cut off, the faucets of the pipes directly supplying the 
clo.sets were open, sewer-air might enter the jiipes ; and it was almo.st positively 
proved that this really had happened. Moreover, this theory very satisfactorily 
explained all the circumstances of the epidemic. 

The volume also contains a report by Mr. J. Nettkn Radcliffe, On Certain 
Means of preventing Excrement Nuisances in Towns and Villages, in which 
are given full descriptions of the various forms of earth, ash, and water-closet 
in use in England, and which is very fully illustrated. This paper will, we 
think, be found a highly suggestive one by those members of our profession 
who are interested in sanitary science — a department of science which, we are 
more than ever convinced after reading this report, is neglected in this country. 
If typhoid lever has rarely assumed here the terribly epidemic form so common 
abroad, it is certainly not owing to the precautions which are taken to guard 
us against its visitations. But inasmuch as the contamination of the atmosphere 
with sewer-gases is one of the most potent sources of this disease, it is a ques- 
tion whether we shall much longer be able to congratulate ourselves on this 
exemption if we intrust so important a matter as the drainage of our houses to 
plumbers, who have no knowledge of the scientific principles upon which it 
ought to be conducted. J. H. H. 



Art. XXIV. — Transactions of American State Medical Societies. 

1. Transactions of the South Carolina Medical Association, Annual Ses- 

sion, 1875. 8vo. pp. 272. Charleston, 187."). 

2. Transactions of the Medical Society of the State of West Virginin. 

Bvo. pp. 150. Wheeling, 1875. 

3. Transactions of the Neio Hamiishire Medical Society, June, 1875. 8vo. 

pp. 169. Concord, 1875. 

4. Transactions of the Medical and Chirurgical Faculty of Maryland, 

April, 1875. 8vo. pp. 226. Baltimore, 1875. 

5. Transactions of the Medical Society of the State of California, 1874 

and 1875. 8vo. pp. 187. Sacramento, 1875. 

6. Transactions of the Minnesota State Medical Society, 1875. 8vo. pp. 

130. Minneapolis, 1875. 

7. Transactions of the Michigan State Medical Society, 1875. 8vo. pp. 85. 

Lansing, 1875. 

8. Transactions of the Indiana State Medical Society, 1875. 8vo. pp. 184. 

Indianapolis, 1875. 

9. Transactions of the Medical Association of the Slate (f Alabama, 

1875. 8vo. pp. 359. Montgomery, 1875. 

1. In addition to the articles contained in the South Carolina Transactions. 

we notice in the minutes of the meeting a somewhat full description, by Dr. 

E. B. TuRNiPSEED, of a set of instruments devised by him for operating upon 

vaginal fistulse and similar cases. Greater ease in the procedure, and greater 

No. CXLL— Jan. 1876. 15 



226 Bibliographical Notices. [Jan. 

success in the result, are claimed for these inventions, in preparing, bringing 
together, securing, and obtaining union between the edges of wounds in loca- 
tions difficult of access. Concerning the real merit of the devices it is im- 
possible to judge from mere verbal description. 

The annual address by the President, Dr. James McIntosh, has for its topic, 
" Ergot, its Hypodermic Use in Hemorrhage, especially Uterine Hemorrhage." 
It is a valuable and thoroughly practical paper. From some half-score of 
cases in his own practice, the writer seems fully warranted in adding his testi- 
mony to that of previous authors, in favour of the almost invariable control 
exercised upon bleeding by the peculiar principle of this drug when taken into 
the circulation. The especial efficacy of the hypodermic administration in 
cases of alarming loss of blood is very cogently illustrated and explained. 
The danger is imminent, and relief, to be truly such, must be very prompt. 

One case is given in which severe nasal hemorrhage concurring with exces- 
sive catamenial flooding placed life in jeopardy. After resisting ordinary 
treatment for thirty-six hours, an injection of ergotine wholly arrested bleeding. 
'J'he author is disposed to believe that the uterine bloodvessels are more under 
the control of this drug than are those of the system at large — apart from es- 
pecial action on the muscular fibres of the womb. 

The extraordinary efficacy attributed by the writer to the hypodermic use of 
stimulants, may lead to the successful treatment of many cases of shock, 
collapse, or prostration, in which the patients are unable to swallow, or to re- 
tain fluids or solids. 

About one-half of this pamphlet, or 135 pages, is occupied with "A His- 
torico-pathological Sketch of 'Bright's Disease,' " being a report of a com- 
mittee upon that subject, appointed by the association. 

To readers not having access to recent European authorities, or lacking time 
to study the voluminous literature of the subject, the report can hardly fail to 
prove useful. The amount of labour performed attests the zeal of its author, 
Dr. Geddings ; while its clearness of arrangement and condensation of style 
equally testify to his good sense and intelligence. 

Another elaborate and carefully prepared paper, of nearly fifty pages, is a 
report by Dr. J. Ford Frioleau, upon " Puerperal Convulsions," which ap- 
pears to be a condensed summary of the ideas of leading pathologists, British 
and continental, as to the character of this much debated and most dreaded 
affection. The writer believes the paroxysms to be identical with those of 
ordinary epilepsy. Dr. Prioleau does not favour treatment by bleeding, but 
rather by anaesthetics, the bromides, chloral, etc. 

Among the reports of cases, and brief papers which complete the volume, 
we find a striking instance of success in the use of cold baths, and ice locally, 
in acute rheumatism, by Dr. S. Bakuch. 

We heartily congratulate the South Carolina society upon their excellent 
publication. 

2. In the Transactions of the Medical Society of the State of West Vir- 
ginia, Dr. S. L. Jepson contributes a brief record of the " Epidemics of Wheel- 
ing." The report covers two or three years, gives the general facts concerning 
the prevalence of puerperal fever, typiioid, cholera, and scarlatina, together 
with many individual cases. The account of the cholera visitation is particu- 
larly worthy of note. 

Dr. W. H. Sharp warmly defends the modern tendency to a free use of 
" Forceps in Midwifery." 

A number of "Surgical Cases," and one of "Ruptured Uterus," selected 



187G.J Transactions of American State Medical Societies. 227 

from the professional experience of many years, are communicated l)y Dr. 
John FiussKt.i,. The writer by no means confines himself to the bare record of 
cases, but uses thera often as texts for not uninstructive comment. 

A few surgical cases and brief reports conclude the number. 

We hope the society will in future aim at a little higher standard of type, 
paper, and proof-reading. 'I'he issue is not very comely, and the value of its 
material is impaired by very many typographical errors. The twenty pages of 
advertisements at the end should not have been admitted. 

3. The Tra7isactio7is of (he New Hampshire Medical Society opens in old 
orthodox form, with an " Address" and an '■ Oration." Among sufficiently 
just views here expressed, as to the duties of the profession in relation lo ed- 
ucation, legislation, quackery, evil literature, and the causation of crime, we 
find in the latter paper what appears to us to be the atrocious sentiment that 
" the public should have the benefit of the doubt, even if thereby a few really 
insane men are executed." 'I'his eminently sagacious and charitable orator 
confidently opines that " the extreme penalty of the law should be meted out, 
surely and speedily, to every murderer who has mind enough to know that he 
performed the act, or that it was wrong to do it. . . ." He further argues 
that. " when this class of criminals know that frightful crimes shall be met by 
frightful penalties, and that, too, surely and speedily, you will find that they 
will be able to control this so-called insane impulse, and it will be the fear of 
punishment that makes them control it." That the frequency with which crime 
escapes adequate punishment should excite honest men to the off-hand expres- 
sion of intemperate opinions, is not altogether strange. 'J'hat a medical man, 
in a deliberately prepared address before his fellows, should so far forget him- 
self, is much to be regretted. 

A practical paper upon plastic splints, with wood-cuts showing their various 
adaptations, is contributed by Dr. G. E. IIkksey. 

Prof. A. B. Crosby, M.D., reports a famous case in which his father. Prof. 
Dixi Crosby, removed, in 1836, at one operation, an arm with its entire scapula, 
and three-fourths of the clavicle. 

Passing over a number of articles of some interest, we notice one by Dr. E. 
CuTTKR, which directs attention to the unfitness of our modern fine white 
flour to support health and growth. We believe there is no doubt that by the 
too fine bolting of wheat meal much of its most valuable nutriment is lost. 
The subject is well worth attention from medical men, especially in connection 
with the dietetic management of children. 

4. The annual oration before the Medical and Chirurgical Faculty of 
Aiar?/Za?id was delivered by Joseph M. Toner, M.D. His principal subject 
was a description of the "Physical Geography" of the State. In foot-notes 
are presented biographical sketches of physicians who have held public posi- 
tions, and of some who were original members of the faculty. The paper is 
illustrated by several topographical profiles taken in different regions and 
directions. It conveys information liable to be of great value to the profession. 

Sectional "Reports" on the recent advances in the different departments of 
medicine, occupy one-half of the volume. That upon " Obstetrics and 
Gynaecology," by Prof. W. T. Howard, deals at some length with post- 
partum hemorrhage, and the " perchloride controversy." Hypodermic in- 
jection of ergotine for the treatment of uterine fibroids, and chloral per rectum 
for the vomiting of pregnancy, are commended from personal experience. At- 
tention is directed to the frequency of unrecognized laceration of the cervix 



228 BiBLioGRArnioAL Notices. [Jiin. 

aferi ; also to the conditious of sncces? in treating lacerations of the peri- 
neum. 

In the report on "Materia Medica and Therapeutics," mercury is defended, 
as a cholagogue, from recent aspersions. 

The localization of motor centres in the gray matter of the hemispheres, the 
minute anatomy of the spinal cord, and of the terminal fibres of the gustatory 
nerves, and of the prostate glund ; the " migration of cells from the blood- 
vessels ;" and some experiments upon the changes in characteristic blood-cells 
after injection into foreign vessels — these are the matters noted in a sectional 
report on " Anatomy and Physiology." 

Among the "voluntary papers" printed, is one upon the nature and action 
of the " Contagium-particles of Eruptive Contagious Fevers." Also one by 
Dr. Theobold, seeking to explain the cause of " Tinnitus Aurium," ascribing 
it to the friction of the blood in the minute vessels of the internal ear. Con- 
siderable ingenuity is displayed in accounting for known facts upon this hy- 
pothesis, and in explaining the altered conditions which render audible the 
naturally quiet circulation. 

Dr. Van Bibbkr describes his adaptation of India-rubber bands for the 
securement of "elastic rela.xation" in some paralytic troubles, as in ptosis, 
facial palsy, and wrist-drop. The bands are so applied as to take the 
place of the weakened muscle. The restoration of a natural position thus ob- 
tained is not merely a convenience, but a valuable therapeutic means. The 
paralyzed part is not only put at rest, but both it and its antagonistic muscles 
are saved from an unnatural and continuous stretching or contraction. Mal- 
nutrition and degenerative changes in both nerve and muscle are thus made 
much less liable to occur, inasmuch as the circulation is much more nearly in 
a normal condition, 

5. Dr. Cluness in the Transactioj^s of the Medical Socidy of California, re- 
cords the unusual prevalence and fatality of scarlatina, in Sacramento. The 
epidemic, at first very mild in its character, almost disappeared for two months, 
but then reappeared in a very severe form. In March, 1875, one-fourth of the 
j-ecorded deaths of the city were from this disease. 

Here as elsewhere we find testimony to the happy effects of ergotine, given 
subcutaneously, in checking hemorrhage and quieting the heart's action. 

A case of supposed encephaloid disease in the lung of a girl of fourteen, 
reported by Dr Tyrrell, is of great interest, but unfortunately incomplete 
through the denial of an autopsy. 

Dr. ToLAND reports a number of plastic operations. The lithographic'cuts 
indicate a very creditable success. 

Great enlargement of the spleen, following an injury, is reported by Dr, A, 
Trafton. By means of the aspirator over seven pints of fluid were removed. 
Two or three weeks later, nearly six pints were removed in the same manner. 
The remaining sv/eliing gradually subsided. A year later the patient reported 
himself in perfect health. 

Several papers on climate illustrate the truth of a statement made by one 
of the writers, Dr. H. A. Dtbois, that almost every variety of climate may 
be fonnd in California; and this without travelling very far. This gentleman 
presents very valuable meteorological tables for the valley of San Rafael. 

6. The Transadionfi of the Minnesota State Medical Society contains ad- 
dresses upon the " Past, Present and Future " of medicine in Minnesota, and 
upon " Psychological Influences in Health and Disease." A successful case of 



1876. J Transactions of American State Medical Societies. 229 

ovariotomy lor cystic tumour, is reported by Dr. Hoyt. Two or three interest- 
ing cases of gunshot wounds and a variety of surgical operations are recorded. 
Spontaneous cure of ii.xillary aneurism is reported by A. W. Danikls, M.D. 
The tumour had a distinct pulsation and thrill. Suddenly when the aneurism 
had become as lar[;e as a man's fist, pain ceased, the faint pulse at the wrist 
wholly disappeared, the swelling became firmcn-, and its pulsation and thrill 
began to diminish. Four months later scarcely any trace of the tumour could 
be made out. The arm continued nearly helpless, carried in a sling, and with- 
onl pulse at the wrist. 

The same gentleman reports the case of a German woman aged 61, who 
bad the handle of a hay-fork driven into the abdomen near the umbilicus. 
Seven hours after the accident he found her lying in the hay-field, in a cold 
sweat, with great thirst and constant vomiting, and pulse feeble and irregular. 
"One-third of the entire intestines, and a portion of the omentum, had escaped 
through the wound." Sponging off the hay-seed and dust, the surgeon returned 
the parts, and, with his hand in the abdominal cavity, rearranged them. Sutures 
and plasters were applied, and the patient conveyed home. Reaction took 
place in the night, she was " comfortable" in the morning, no peritonitis ap- 
peared, wound healed by first intention, and recovery was " rapid and com- 
plete." Opiates and stimulants were given 'as freely as required." 

7. At the last meeting of the Michigan Society a temperate protest was 
offered against the course of the Slate University in aduiitting homoeopathic 
teachings. It was deemed wiser, however, after some discussion, to table the 
whole matter. It was voted to request the Detroit Medical College to raise its 
standard of preparatory acquirements, and to extend its term of instruction.' 

To say that the presidential address is by Dr. R. 0. Kkdzie, is, to those who 
have read his papers upon sanitary science in the State Health Reports, full 
assurance of superior merit. His subject is "Ozone." 

Dr. EuGENR Smith, of Detroit, briefly states the lessons he has learned from 
one hundred operations for cataract, performed by Graefe's method. Less 
depends, he believes, on the exact size or position of the incision — within rea- 
sonable limits — than upon completeness of removal, and the after treatment, 
particularly the latter. He estimates the results as in 90 per cent, good 
success, 7 per cent, partial success, and 3 per cent, failure. 

The subsequent treatment is considered to be particularly important. Unless 
some cortical substance is left, he uses at this time no atropia. Circlets of soft 
linen upon the closed eyes, with charpie enough to fill the orbital depressions, 
are surmounted by a flannel bandage of two thicknesses. These should be 
removed the evening of the operation, and again the next morning. One removal 
with cool bathing of the eye, may be enough, daily, thereafter; though for a 
few days twice a day is better. On the second or third — except as before noted 
— he begins the use of atropia. If much pain appears on the third or fourth 
day, he examines the iris, and if inflammation threatens, gives mercurials with 
anodynes. The bandage is ordinarily continued a week ; and then left off a 
short and increasing time daily, at first in a darkened room and with a green 
shade over eyes. 

A case of supernumerary testicle [perhaps two], simulating hernia, is re- 
ported by Dr. Peter Stewart. 

Dr. Stoddard calls attention to the not sufficiently appreciated virtues of 



' The same request had previously been addressed to the medical department 
of the State University. 



230 Bibliographical Notices. [Jan. 

permangauate of potash. As a disinfectant he believes it equal to any, if not 
better. As a destroyer of disease-germs, and a promoter of healthy action in 
ill-conditioned suppurating surfaces, he believes it to be unequalled. He has 
found it singularly useful in ulcerations of the mouth and throat. 

8. In a paper read before the Indiana Slate Medical Society upon " Puerperal 
Eclampsia," Dr. S. M. Martin earnestly advocates the treatment by venesection. 
He presents a table of results in some ninety cases, which he has collected from 
medical journals. This gives, with bleeding, one death in fifteen; without, one 
in four or five. Dr. Harvey reports a single case, just happened in his prac- 
tice, where he believes life was saved by hypodermic injection of morphia, with- 
out bleeding, which he deemed unadapted to the particular case. A somewhat 
general discussion followed the reading of these two papers, which showed that 
a large proportion of the Indiana faculty still rely upon the lancet in many or 
all cases of this disease. 

An amusing story is told by Dr. Lomax, how, many years ago, twenty grains 
of quinia was given by mistake instead of calomel, to a patient with bilious 
fever. This blunder was then considered about as dangerous a one as could 
well be made, short of absolute, deadly poisoning. Hence the astonishment of 
the physician may be imagined when, ne.\t morning, he found his patient wholly 
relieved from fever, pain, and headache, and in a general perspiration. The 
cure was speedy, and the physician had sense enough to profit by the lesson. 

Dr, Joseph R. Beck gives some remarkable instances of the curative power 
of iodide of potassium in even the most advanced and apparently hopeless 
cases of tertiary disease. He uses it also in the secondary stage to the exclu- 
sion of mercury. 

Dr. Geo, Sutto.v reports some remarkably interesting cases of trichinosis 
from eating uncooked pork sausage. 

Of five hundred swine whose microscopic examination he has recorded, the 
doctor found forty-eight diseased. 'I'wo hundred and forty-five from another 
neighbourhood were reported by medical friends to exhibit the parasite in forty; 
while two hundred from yet another district yielded only thirteen cases. 

Very important comments and inferences are added by the writer, which we 
must omit. 

We are sorry that a little more care had not been exercised in revising this 
handsome volume. Good paper, and fine, clear type should be especially sacred 
from bad gramra vr, and gross errors of spelling. In one score of pages, 
without looking very closely, we noticed ten misspelled words. " Menstruar- 
tion" for "measuration" might be excused, if it were the only blunder of its 
kind. 

9. Again we have occasion to congratulate the Alabama Medical Associa- 
^^or^ upon a publication every way creditable, 'i'he papers presented, however, 
are in number comparatively few. Several of them, too, are of a character that 
render it difTicult profitably to analyze or condense them. If then we give 
less space to this volume than to some smaller ones, it is not from want of ap- 
preciation of its value. 

We learn with pleasure that the Association has been constituted, by recent 
legislation, a Board of Health for the State. A Committee of Public Health 
has been appointed to assume and discharge the new functions thus imposed. 

The important objects to be attained, and the methods to be used, by the 
newly created committee, are considered by President J. S. Weatheri.y, M.D., 
in his address upon "State Medicine and Preventable Diseases." 



1876.] Otis, Report on Plan for Tiansporting Woiiiulcd Soldiers. 231 

" Medical Ethics" is the theme of the annual oration by Dr. Kktcmum. The 
spirit of the effort is pood, and the style vigorous. 

In a paper upon "Tuberculosis and Scrofulosis," Dr. E. V. Gaines sets forth 
the arguments against the identity of these two conditions or tendencies. 

Dr. M. Kkitiikn records the birth of dissimilar twins from a very dark negro 
woman "with kinky hair and flat nose." One child was "bright-coloured" 
with hazel eyes, and straight, reddish sandy-looking hair. The otlier was black 
in complexion, eyes, and wool, with flat nose and thick lips. The lawful father 
of the twins was as full-blooded an African as the mother. Nothing is said as 
to any suspected paramour. Besides referring to similar cases in the books 
the writer describes one striking instance, heard of by iiim at third hand, which 
apparently has not been published. Here the unlooked-for return of a hus- 
band, on a night when his wife had received consolation from a male friend, 
was duly followed by the birth of twins — one dark in eyes, hair, and skin, and 
the very image of his father; the other blue-eyed, blonde, and resembling the 
friend of the family, who, it was afterwards confessed by the woman, had hastily 
escaped from her bed at the sound of the husband's approach. 

Dr. BizzEix contributes a paper on the " Climate of the United States" with 
reference to consumption and pneumonia, lie points out first those regions 
and spots which favour the origin or progress of these diseases, and second, 
those which are comparatively exempt from them, or in which patients obtain 
cure or relief. The latter division of the paper is quite full, and states in a 
sensible and discriminating manner the peculiar merits and demerits of our 
different resorts for invalids. 

One-fourth of this volume is occupied by Dr. Jerome Cochran, in a very 
full and instructive account of the "Smallpox J^pidemic" as it occurred in Mo- 
bile in 1874-5. The writer does not confine himself to the bare facts of the 
epidemic, but discusses the natural history of the disease, its dissemination, 
relations to seasons and to races, and especially its prevention or limitation. 
"Vaccination is fully considered. The writer does not admit the superiority of 
bovine virus. 

A case where epilepsy followed the projection into the brain of a sharp piece 
of steel, and was cured by its removal after two years, is very imperfectly re- 
ported. 

Several other reports and cases conclude this interesting volume. 

B. L. R. 



Art. XXV. — A Report, on a Plan for transporting Wonnded Soldiers hy 
liailway in time of War, ivdh Descriptions of various Methods employed for 
this purpose on differerd occasions. By George A. Otis, Assistant Surgeon 
U. S. Army. 8vo. pp. 56. Washington, War Department, Surgeon Gen- 
eral's Office, 1875. 

The pamphlet before us is a report from the pen of Assistant Surgeon Otis, 
U. S. A., concerning the transportation of sick and wounded men in time of war. 
The author modestly regards his examination of the subject as "cursory;" in 
reality it is a careful and elaborate study of the experiments and experiences of 
different nations upon this important subject. 

The immediate cause of the publication is a reference by the Secretary of 
War to the Surgeon-General of a paper forwarded to the former through diplo 
matic channels by a Russian engineer, Mr. A. Zavodovsky. The latter proposes 



232 Bibliographical Notices. [Jan. 

a system of railway transportation for wounded and sick soldiers, which can be 
extemporized at any railway terminus in the vicinity of a battle field. 

In the opening paragraph of his report to the Surgeon-General, Dr. Otis 
alludes to the important influences which railway lines exert upon military and 
strategic combinations. As these, he informs us, greatly increase the destructive 
powers of armies ; so do they also " offer a useful and most effective means of 
saving lives and alleviating suffering, by the speedy removal of the sick and 
wounded from the scene of active operation." As we are told, some military 
surgeons, and we believe indeed most, hold that the men wounded in the great 
cavities, or with gunshot fractures of the thigh or large joints, should not be 
subjected to the risks of transportation, but should be treated in hospitals as 
near as possible to the field. At the same time, every one admits the propriety 
of the rapid removal of as many as possible, " the great bulk of the sick and 
wounded" of an army, a removal, however, to be governed by strict inspection, 
and a proper regard as to the speedy return of convalescents. 

The advantages of such a course, as Dr. Otis remarks, will be found in the 
retention of a large proportion of medical officers with their proper commands ; 
in the reduction of the amount of medical and hospital supplies necessary for a 
marching army, and in the lessening of depot hospital accommodations for malin- 
gerers. Then, too, if by convenient railway transporation, the wounded can 
early be placed in proper permanent hospitals, " many primary mutilations 
may be justifiably avoided, with a view of employing more delicate special opera- 
tions, when the patients arrive at a safe place of rest. Lastly, the most impor- 
tant consideration is the most obvious, the distribution of sick and wounded 
prevents the generation of those pestilences that are the greatest scourge of 
armies. The sick and wounded avoid infecting each other, and those who are 
well, escape contagion." 

From these general considerations, the writer passes to the special railway 
transportation of the disabled, which has been practised in different wars. This 
was first done in the Italian war in 1859, by the Austrian, French, and Sardinian 
armies. It was afterwards adopted by the Prussians in the Danish war, and 
also in the war with Austria, in 1866. 

We have not space to follow Dr. Otis in the accounts he gives of the railway 
transportation of the sick and wounded of our own civil war, from the armies 
of the Potomac, and the different ai-mies of the AYest. The composition of the 
various hospital railway trains is carefully described, and the details of the con- 
struction of the hospital £ars, and the mode of suspension of the litter-beds, are 
entered into with much minuteness. Concerning the hospital trains of the 
army of the Cumberland, probably one of the best, if not the best organization 
of its kind in the U. S. army, we are informed : — 

" General Thomas accorded the fullest authority to Medical Director Cooper, 
to select for tlie hospital trains the best locomotives and cars to be found among 
the rolling stock, and to have new cars fitted up whenever necessary, and caused 
to be detailed for the hospital service the most experienced conductors, en- 
gineers, and other employes of the several railway lines. Medical Director 
Cooper infojms the reporter that the smoke-pipes of the locomotives of the hos- 
pital trains were painted of a brilliant scarlet; the exterior of the hood and of 
the tender car with water and fuel, wt-re of the same conspicuous colour, with 
gilt ornamentation. At night, beneath the head-light of the engine, three red 
lanterns were suspended in a row. 'J'hese distinguishing signals were recognized 
by the Confederates, and the trains were never firod upon or molested in any 
way. Dr. Cooper ' was informed by wounded Confederate officers in Nashville, 
who were captured at the battle near tliat place, of the stringent orders given 
his troopers by General W. B. Forrest for the non-interference with and protec- 



1876.] Otis, Report on Plan for Transporting Wounded Soldiers. 233 

lion of the U. S. A. hospital trains.' hy ?ivin<; them timely warning in the 
event of tlic railway beiuj,' ohstructed or turn iij). The partisan troop.-^ of Col- 
onel John Mdvpan's command had similar instructions. It is related that on 
one occasion Colonel Morixan's scouts stopped the train directed by Dr. Barnum, 
and havinjr switched it oft' upon a siding, after inquiring if there were sufficient 
stores on the train for the sick and wounded, they tore up the main track, and 
then rifled and destroyed five supply trains that successively arrived at the point 
where the line was interrupted." 

Among the Confederates, railway transportation for wounded was also largely 
employed, although, owing to the paucity of resources at the command of the 
Southern government, the cars made use of possessed few of the niceties of 
accommodation which marked the hospital trains of the U. S. armies. ' As a 
rule the Southern wounded were removed in freight cars and flats, the floors 
of which were covered with straw, and indeed more often with leaves, hemlock, 
and pine or evergreen boughs. The objection to this plan, as would naturally 
be expected, was the tendency of this improvised bedding to become foul. 
Stretchers were scarce, and the Confederate surgeons were obliged to make the 
best use they could of blankets and spreads. In some instances passenger cars 
were used, provided with bunks. 

At page '2i we are furnished with the results of the experiments of the inter- 
national conference held at Paris in 1867, under the presidency of the Due de Fe- 
zensac. On this occasion every variety of railway equipage was tested, the trains 
being run by the Commission around the suburbs of Paris. A spring stretcher 
invented by .Mr. Gauvin, m^decin-major in the French army, and intended to rest 
upon the car floor, was regarded as the most comfortable arrangement. A straw 
mattress laid directly upon the car floor was found to be the most objectionable. 
As a natural consequence, the experiments at the Paris Exposition gave rise tea 
wide discussion upon the subject of railway transportation of the wounded. 
and many most eminent military surgeons became interested in the matter, 
and pressed their views upon their respective governments. Among those who 
did so were Esmarch, Roth, Gurlt, Virchow, Liiwer, Sigel, Le Fort, Gauvin, 
Billroth, Muudy, and others. AYe have already had occasion, in a former notice, 
to refer to the magnificent atlas, published by Prof. Gurlt, upon tlie trans- 
portation of wounded in time of war. 

The remaining pages of Dr. Otis's pamphlet are occupied by an account of the 
Prussian, Spanish, Hamburg, Baden. Russian, and Bavarian systems of railway 
transportation for the disabled. AVe would willingly devote more space to 
their examination, but the numerous technicalities render difficult a proper 
display of the subject within the limits of a book notice. We can only refer 
those interested to Dr. Otis's pages. Comparatively lew as these are, they teem 
with information, and lead us to anticipate with pleasure the more extended 
account of railway transportation for wounded which we are promised, in a 
future volume of the Surgical History of our War. 

In putting aside, however, this unpretending report of Dr. Otis, we cannot 
refrain from testifying our appreciation of its value. It is marked by the usual 
industry and research characteristic of its author, and in its way, is quite in 
in keeping with those other publications which have from time to time ema- 
nated from the office of the Surgeon-General ; and which tend to the credit of 
the Medical Department of the Army, and to the renown of American Military 
Surgery. J. H. B. 



234 Bibliographical Notices. [Jan. 



Art. XXVI. — Lectures on Diseases of the Nervous System. By Jerome K. 
Bauduy, M.D., Professor of Psycholojrical Medicine and Diseases of the 
Nervous System and of Medical Jurisprudence in the Missouri Medical 
College, etc. Reported by V. Biart, M.D., Revised and Edited by the 
Author. 8vo. pp. 484. Philadelphia: J. B. Lippincott & Co., 1876. 

Dr. Bauduy's book is one of the best American works we have upon the 
diseases of the nervous system, although there is absolutely very little in its 
pages that adds to our knowledge of the subject. It is an excellent epitome, 
however, and is written in a clear, readable style, well adapted to the general 
practitioner and the student. It is in no way a profound book, but rather a 
guide in the diagnosis and treatment of this large class of difficult cases. We 
have looked in vain for anything like a thorough and careful consideration of 
morbid anatomy. 'J'his part of the subject is of such vital importance in neuro- 
logy, and has been so well opened up to the student by the French histologists 
partioilarly, that we are surprised to sec it slighted in the volume before us. 

In the disposal of matter, the author has done his work systematically, and 
arranged his subjects with good judgment. The diseases of circulation of the 
brain and cord are placed with regard to their anatomical situation, and the 
author displays the same good taste and familiarity with his subject through- 
out the book. Cerebral hyperaemia, and anaemia in its various forms, are dis- 
cussed first, partial and collateral anaemia being particularly well worked up. 
Meningitis and its different varieties come ne.xt, and nearly a hundred pages 
are devoted to insanity. We must commend these chapters, as they show the 
fruits of experience and study, and have tlie merit of being original. The 
author occasionally wanders into a style of expression that perhaps is just a 
little too florid for a medical book. On page 151 our author says, for exam- 
ple : " I compare the brain to the asolian harp, whose strings, set in vibration 
by the passing wind, give forth euphonious sounds." 

In his description of general paralysis, he omits, we think, two very impor- 
tant early symptoms, viz., the trembling of the lips and tongue. We also diGfer 
from him in regard to the appearance of the paralytic symptoms, which, we 
have always been taught, were secondary conditions following long after the 
appearance of mental delusions of wealth, etc. — an important condition, which 
the author also omits, is the violent stage, when irritability is marked, and 
when homicidal tendencies are generally present. The chapter on " Melan- 
cholia" is excellent. Dr. Bauduy devotes several pages to hypochondruisis, 
■which are interesting. The protean forms of this undefined condition, and the 
recent observations abroad, and in this country, have suggested fruitful themes 
of study. The vague nature of hypochondriasis, hysteria, and the class of 
cases that come under the head of dyscesthesia, puzzle the physician very fre- 
quently. They must sometimes be due — very often, we think — to physical 
causes, and the patients, instead of being " poo-poohed," really deserve the 
sympathy and medical treatment of the doctor. 

Apoplexy and cerebral hemorrhage are next discussed by Dr. Bauduy, but 
very little attention is paid to regional diagnosis. 'I'iie question of blood- 
letting is considered, and condemned by several pages of quotations. Epilepsy 
receives a very graphic description in the succeeding pages. 

We do not, perhaps, attach as much importance as the author does to loss 
of memory as an earli/ symptom of the disease, nor to wetting or defiling of 
the bed linen as evidences of the nocturnal variety of attack. In this latter 



1876.] Bauduy, Lectures on Diseases of the Nervous System. 235 

form, wo tliink, it is of the utmost impartance that some one should sleep with 
the suspected person, if we are in doubt as to the nature of the trouble. 

The author advocate.^ the l)romide treatment, and quotes Hammond's sug- 
gestion that strychnia should be given for the diurnal forms. The eflfect of 
this latter ageut, we think, must be to increase any disposition to refle.K irrita- 
bility. He dues not recommend the nitrate of silver, but says: " I have no 
comments to make upon it, e.xcept that I regard it as a positive failure; and, 
besides, its continuous administration gives an indelible blue discoloration to the 
skin." We cannot fully agree with the author in this matter after reading the 
results of Wunderlich, \''an der KiJlk, and others. We also think the dangers 
of discoloration are greatly exaggerated by most writers. Seguin, of New 
York, in a large number of cases treated with this salt in large doses, has 
never produced the slightest discoloration ; and it is the writer's opinion that 
much larger doses than are laid down in the text-books can be given for a long 
time without any trouble. Dr. Bauduy endorses ergot, which is an admirable 
remedy. 

The medico-legal relations of epilepsy are well handled, and form an agree- 
able feature of the book ; no work that we know of goes so fully into the sub- 
ject. 

Chorea is made the subject of the next lecture. The author, we think, errs 
in advising electricity as a means of cure. We think the general opinion of 
those who have tried this remedy, with the exception of the late Golding Bird, 
is, that its action is productive of no good whatever. The ether spray, which 
he advises with caution, is, however, we think, a most valuable form of treat- 
ment. 

Lead palsy and various other local paralyses are considered next, and alco- 
holism receives extended mention. Dr. Buuduy's treatment of this condition 
is to deprive the drunkard at once of his drams, and, from his own account, 
has done more to check the disease than if he had " tapered off"." Sclerosis, in 
its different forms, is passed over rather hastily, and Facial Paralysis, to which 
the author has given its old name, BeWs paralysis, form the subject of the 
succeeding chapters. We do not think sufficient attention is paid to these 
forms of paralysis. 'I'he diagnostic points in both are very important. We 
take opposite sides with the doctor in regard to the paralysis of the orbicularis 
palpebrarum. We do not see any reason why certain effusions should not 
produce it even when there is hemiplegia, which he denies. In lead paralysis, 
the study of differential diagnosis between this and certain other peripheral 
paralyses might be dwelt upon more extensively than it is. 

The author considers the subject of cerebral tumours at length. He adopts 
the divisions of Jaccoud, and divides them into vascAilar, parasitic, constitu- 
tional, and accidental. This classification is that adopted by Hammond, but 
we prefer the plan of Rindfleisch, who divides them according to their ana- 
tomical situation. Dr. Bauduy and Jaccoud place in their tables aneurisms 
and vascular growths, which would come better under the head of lesions of the 
vessels, and should be discussed in their connection with intra-cranial hemor- 
rhages ; however, this is a small matter. We think more might have been said 
of the history and appearance of syphilitic tumours, which the author dismisses 
with four lines. Locomotor ataxia is well described, and the diagnostic points 
nicely taken. We must differ from the author, however, in his statement that 
lesions have never been found in the cerebellum. If the author will consult 
Charcot's admirable work {Legons sur les Maladies dit Systime nerveux, PI. I., 
Fig. 2), he will learn that this investigator found sclerosed patches in the 
cerebellum in several instances. Both Charcot and Bourneville have done 



236 BiBLiooHAPHiCAL NoTicES. [Jan. 

so much to make the subject of sclerosis clear, that we wonder Dr. Bauduy 
has not referred to them more frequently, instead of to certain American 
authorities, whose investigations are of far less value than those of Moxon, 
Charcot, or Bourneville. Diphtheritic paralysis receives extended notice, and 
is one of the best chapters in the book. The remainder of the work is devoted 
to the consideration of the various infantile paralyses, aphasia, syphilitic affec- 
tions of the nervous system, and neuralgia. The author does not allude to the 
"spinal paralysis" of adults, nor does he dwell upon the distinctions between 
this condition and others as regards the non-involvement of the rectum and blad- 
der. There is nothing so distinctive about syphilitic neuroses that they should 
be classified by themselves. Syphilis is so often at the root of organic nervous 
diseases, that it should be considered as one of the great causes and be scat- 
tered through the book. A word of praise is due the author for the admirable 
chapter upon neuralgia, which is neatly written and full of excellent suggestions. 
Glosso-labio-pharyngeal paralysis might have been dismissed in a page or two, 
or included under the head of sclerosis, of which it is only a localized form, as it 
is a condition which is almost a curiosity because of its rarity. Hydrophobia, 
tetanus, and several other important diseases are not considered at all. 

One agreeable feature of the book is the author's modesty. We have not 
found any recitals of unimportant cases, or uninteresting personal details that 
find their way so often into book^i to advertise their author. 

Dr. Bauduy's work presents a fair r4sum6 of our knowledge of nervous dis- 
eases, and will be read, we doubt not, by all medical men who are interested in 
this important branch of study. A. McL. H. 



Art. XXVII. — Cydopcedia of the Practice of Mediciiie. Edited by Dr. H. 
VON ZiEMSsEN. Vol. X. Diseases of the Female Sexual Organs. By Prof. 
Carl Schrceder, of Erlangen, Bavaria. Albert H. Buck, M.D., New York, 
Editor of American Edition. 8vo. pp. viii., 575. New York : William Wood 
and Co., 1875. 

From the three volumes of " Ziemssen" previously issued in this country the 
profession quite well know how ably Dr. Buck and his collaborators are doing 
their work, and in what handsome form the American publishers are presenting 
this invaluable Cyclopaedia. 

" Schrceder" presents many obvious excellences. Upon even a casual exami- 
nation, one is struck with the numerous, admirable illustrations, most of them, 
indeed, new, at least to American eyes. While, however, these illustrations are 
all to be commended as matters of art, so clear, so well defined, we are inclined 
to question the anatomical accuracy of a few at any rate. For example, we 
are decidedly sceptical, as to the power of a distended bladder to detach the 
peritoneum from almost the entire anterior portion of the uterus : such detach- 
ment is represented in Fig. 54, p. 160. Still less do we believe that the thick- 
ness of the urethro-vesico-vaginal wall is an inch or more, and yet one must 
believe it, if Fig. 55, page 164, be correct, for the observer will there see it rep- 
resented with a diameter almost, if not quite, equal to the base of the perineal 
triangle, t. e., the distance from the vaginal to the anal orifice. And then we 
have on page 77 an hypertrophicd cervix protruding from the vagina, and a 
counterfeit presentment of — What shall we say ? — either a misplaced shawl pin, 
or a drop of mucus with a protracted caudal projection clinging to the os uteri 



ISYH.] Cyclopaedia of tlie Prncticc of ML-dicino. 237 

like an opossum or a monkey snspendod by its tail to the l)raDch of a treo. But 
let these trifles pass. 

Another obvious, and, so far as works on diseases of women are concerned, 
almost peculiar merit is the presentation, very brief, however, of the intra- 
uterine development of the female sexual organs. The study of the embry- 
olory of these orjrans not only i.s important with reference to a knowledjje of 
their ultimate structure and form, but also enables one to understand anomalies, 
which are generally arrests of development, so that embryonary states, which 
should have been temporary, by their permanence have become teratologic. 
Another very commendable feature in this work is the very complete biblio- 
graphy preceding the discussion of each subject. 

Book makers, at least, in scientific departments of knowledge, would confer 
a great favour upon, or rather do a just thing to their readers were they to 
pursue a similar practice. How often does the student wish to consult origi- 
nal authorities, rather than take the interpretation of another ! or else he de- 
sires fuller or related knowledge. 

yhall we mention the conservative character of Prof. Schroeder's teaching as 
a capital merit? Illustrating this conservatism, let us quote his words, as to 
retaining the term, chronic niefritis, and this we do the more promptly, since 
in reviewing in this Journal, the last edition of Thomas's unequalled work, we 
gave expression to views somewhat similar. 

Schrceder declares it his " conviction that we cannot dispense with the clini- 
cal picture of chronic metritis, for we should ot icrwise be obliged to separate 
closely connected pathological conditions having the same symptoms and re- 
quiring the same treatment. 

"Neither do I consider the term, 'chronic metritis' to be so very improper, 
because it is probably nothing more than a war of words, whether that condi- 
tion be called hyperplasia of the connective tissue of a hyperajmic uterus, or 
the product of an exceedingly chronic inflammation. 

•' Indeed, [ should be loth to dispense with the name ' inflammation' for this 
very condition, partly because the treatment needs to be decidedly antiphlo- 
gistic, and partly because in the early stages we always have the clinical symp- 
toms of inflammation — hypertemia, tumefaction, and pain." 

Other illustrations of the conservative character of the instruction in this 
work will be found in the restricted use of the uterine sound, and in the surgi- 
cal treatment of fibroids. 

Another merit of the work, especially commending it to American readers, is 
the just recognition given to American gynsecologists, more particularly in the 
department of the surgery and the mechanical therapeutics of uterine diseases. 
Take away from this work all that was originally derived from McDowell, 
Hodge, Sims, Emmet, and Thomas, and possibly as much as one-third of it 
would be struck out. It is quite satisfactory to know that our country has 
contributed its full contingent to the therapeutics of diseases of women. 

Passing from these general considerations to some of the special subjects of 
the work, we can heartily commend the chapter upon gi/ncecological examina- 
tion as clear, succinct, complete — indeed, every way satisfactory, only pausing 
to put in a plea for valvular specula which Schrceder states " are now but little 
used." As to quadri-valves and tri-valves the statement doubtless is true, but 
we believe that in this country no speculum is oftener or more in use by general 
practitioners than Ousco's, or some modification thereof; while the specialist 
having an assistant or trained nurse will hold to the duck-bill, since he has 
some one else to hold it for him, the physician in general practice will not fail 
to have a bi-valve, for he needs an instrument easily introduced, one that is 



238 Bibliographical Notices. [Jan. 

self-retaining, and one that will secure separation of the uterine lips rather than 
their approximation, which is so usual with cylinilrical specula. The fragility 
of the more common cylindrical specula is another reason for their use being 
limited. When we add to all that has been said such specula have no power of 
accommodation in size to the requirements in the examination of different pa- 
tients, we think we have adduced sufficient reasons for a just preference for a 
bi-valve speculum over a cylindrical for general use. 

r^ollowing examination we have diseasi^s of the uterus. 

Unilateral hcematometra, with duplication of the genital canals, is Schroeder's 
periphrastic designation for a condition termed by Puech' more than ten years 
ago complex atresia. Quite recently^ the latter has given a thorough study to this 
anomaly, analyzing a large number of cases, and in some of his conclusions he 
differs from Schrceder. Schroeder asserts the danger is not so great in com- 
plex as in simple atresia, and advises puncturing with a trocar the blood- 
collection. Puech, on the other hand, asserts that complex atresias have the 
same termination as simple; that the liability to intra-peritoneal rupture is 
greater in the former than in the latter, one in ten and one-tenth in the com- 
plex, one in twenty in the simple : that the mortality after an operation in the 
complex is one in three and a half, and finally he directs that in operating the 
opening should be by free incision, and not by simple puncture. 

The treatment of chronic metritis is very fully given. The author is quite 
positive in recommending scarification of the vaginal portion of the mucous 
membrane of the cervix, giving a decided preference to this method of depletion 
over that by leeches. 

In chronic endometritis he advocates intra-uterine injections. 

AYe must differ with Schroeder in his unqualified endorsement of scarification 
and his rejection of leeches in the treatment of chronic metritis. Experience 
differs, and that of no one individual is sufficient to establish an absolute rule 
of practice. We have never had any serious result from leeching the cervix, 
and we have had a fatal peritonitis from scarifying. 

Let any one after reading Schroeder's discussion of metritis and of endo- 
metritis turn to Gallard's Lectures upon the same subjects, and bring to the 
test of his own experience the conflicting statements of the two authors as to 
the existence of leucorrhcea and menorrhagia in these disorders, and we feel 
confident that he will regard those of the latter as more nearly correct. 
Schroeder makes menorrhagia, also, " not unfrequently a flow of blood inde- 
pendently of menstruation," and leucorrhcea among the characteristics of 
chronic metritis. So, too, in chronic endometritis we have in addition to the 
catarrhal discharge " which gives the disease its popular name," very commonly 
hemorrhages, metrorrhagia, and menorrhagia. Gallard, on the contrary, asserts^ 
that in chronic parenchymatous metritis, we do not have hemorrhages, or they 
are scanty, while in internal metritis they are abundant and persistent, while 
a persistent leucorrhcea is the indication of some change in the lining mem- 
brane of the cervix or cavity induced by inflammation. 

A little more than three pages are regarded as sufficient for the consideration 
of erosions and ulcers of the vaginal portion of the uterus ; this statement shows 
how wonderfully the opinions of the profession have changed within a lew years, 
as to the importance of these lesions. 

• De I'Atresie des Voies genitales de la Femme, Paris, 1864. 

2 Anuales do Gyiiecologie, 1875. 

3 Leij-ous sur les Maladies des Femmes, Paris, 1873, 

* pp. 308 and 434, op cit. 



1876.] Cyclopoedia of the Practice of Meclicine. 239 

In flexions of the uterus, Schrcuder uses a stem pessary, and then to prevent 
version a tampon of cotton is so lixeil as to retain the bull) of the stem' in such 
position that anteversion or retroversion cannot occur; in this mauipuhition it 
will be observed that tlie pessary is used instead of a sound to remove /?t'x/o?(, 
and then the succeeding version is rectified by the tampon — certainly an in- 
genious treatment. 

The discussion of uterine fibroids is exceedinjjly interesting, especially that 
devoted to the changes that occur in these growths. In referring to the 
medical treatment the very just remark is made "we have no internal 
treatment from which in any individual case, we are justified in expecting good 
results with the least degree of certainty." 

In speaking of surgical operations upon fibroids, Schrceder says, "these 
tumours may be reached in two ways, either through the vagina and cervix or 
through the abdominal walls by laparotomy." A third^ way has been shown 
practicable in some sul)peritoneal fibroi(is,by Dr. Wiiitehead, of Manchester, viz., 
removal by incision through the vagina in the utero-rectal cul-de-sac, an opera- 
tion similar to that known as vaginal ovariotomy. 

In regard to the enucleation of fibroids, has not the danger been exag- 
gerated? Pozzi^ gives the results in sixty-four cases of enucleation; death 
ensued in fifteen, or one in about 4.25. Among the operators were Amussat, 
Boyer, Lisfranc, Maissonneuve, Baker Brown, Atlee,** Sims, Thomas, Martin, 
and Koeberl6. 

In regard to the etiology of cancer of the uterus, Schrceder introduces the 
statistics of Glatter, showing the much more frequent occurrence of the 
disease in married than in single women. In reference to its pathological 
anatomy he adopts the views of Waldeyer, who refers the origin of all the 
forms of cancer to the true epithelia, considering them all as epithelial tumours, 
which develop, without exception, from actually existing epithelium ; and thus 
cancer differs from sarcoma which originates in the connective tissue.^ 

Holding to the local origin of cancer, he anticipates no result from internal 
remedies. Removal of the diseased portion is the first and most important 
step. When the cervix is the part involved, it should be amputated with the 
wire ^craseur, or with the galvano-caustic loop ; if the former is used, subse- 



' While referring to stem pessaries, we wish to enter a positive protest as a 
victim of misplaced coufideuce, in the galvanic pessary of Sir James Simpson, 
furuislied by some instrumeut makers and dealers. The bulb of Sir James's in- 
strument is hollow aud made of copper ; but these wicked inventions of an enemy 
to the true instrument have the bulb made of solid ebony, sufficiently heavy to 
insure its certainly dropping down and pulling the stem out of the uterus ; such 
are excellent instruments of annoyance to tlie doctor and of uselessness to the 
patient. 

2 British Medical Journal, 1S71. 

3 De la Valeur de I'Hysterotomie dans le Traitement des Tumeurs fibreuses de 
rUterus, Paris, 1875. 

* Pozzi, in referring to one of Dr. Alice's cases, makes the following ungracious 
remark : " En estimant le poids de la tumeur k pres de ' 10 livres,' le Dr. Atlee 
commet una grande exageratiou ; cette remarque pent s'appliquer h presque tous 
les poids donner par lui." 

5 Wagner, however, asserts that cancer may originate in the connective tissue, 
as well as in the epithelial, and hence the varieties ; scientific opinion is at 
least unsettled as to the correctness of Waldeyer's views, and, indeed, we may 
readily adopt the statement of Richerand quoted in a recent number of the 
Archives Gen/rales, Cancer is as difficult to dfjine as to cure. 



240 Bibliographical Notices. [Jan. 

(juently cauterize the surface with the hot iron. If all the affected tissues 
cannot be removed by a surgical operation, cauterize with an alcoholic solu- 
tion of bromine, one of bromine to five of alcohol ; so, too, hypodermic 
injections of this solution are made into cancer tubercles. In certain cases 
Simon's sponn-i are nsed to remove the cancerous infiltration, and in this 
connection the following extraordinary statement is made : " I have penetrated 
so far with the spoon that the newly formed excavation was for a considerable 
space separated from the bladder, as well as from the rectum, only by the 
intact mucous membrane of those organs." 

A very interesting essay upon normal menstruation, is succeeded by a very 
brief consideration of the derangements of menstruation. Nearly three pages 
for amenorrha'a, a little more than a page for menorrhagia, and six and a half 
for dysmenorrha?a — only ten or eleven pages in all for disorders that meet the 
physician every day ! 

One of the most interesting parts of the volume is that devoted to ovarian 
tumours ; here there can be no complaint of hurried and imperfect treatment 
of the subject. 

Almost immediately following ovarian diseases are perimetritis and parame- 
tritis, for the former pelveo-peritonitis is used as a synonyme; as we already have 
])elvi-peritonitis, we see no reason for the new term. In regard to the vexed 
question as to which of these disorders is the more common, Schroeder remarks 
t\iVii parametritis is a connective tissue phlegmon, which is due to an infection 
with septic material ; hence, that it is common in the puerperal state, but at 
other times is tolerably rare, and that p>erimetritis is a partial peritonitis, 
which may be, and frequently is, induced by the most diverse causes. 

Diseases of the vagina and the vulva conclude the volume. Under the 
former of course we have uro-genital fistulce and their treatment ; the latter, 
giving Simon's operation, is not full enough of detail to be a sufficient guide 
alone for any one in operating. Schroeder asserts that in fistula of the ureter 
transverse obliteration of the vagina offers the only possible means thus far 
known of effecting a cure. Some women are getting along quite well without 
ovaries, relieved of, to them, those useless and injurious appurtenances by the 
brave and brilliant operation of a distinguished surgeon of Georgia ; an eminent 
physician of "Washington has demonstrated, at least to his own satisfaction, 
that women should not menstruate " in the typical perfection of their sexual 
organs," and why in all wonder should any one of them, who has a rebellious 
urinary fistula, be allowed to have a vagina? Besides, the moral efi'ect of 
obliteration of the vagina would be excellent, chastity secured quite as certainly 
as ever the infibulation of a past age did. 

But really uretero-vaginal fistulae demand no such radical treatment as 
vaginal occlusion. Duclout,' and Deroubaix,^ whose exhaustive work we are 
surprised to fiid Schroeder makes no reference to, have each proposed ope- 
rations for this lesion that are much less serious than, and quite as certain as 
Simon's for the closure of the vagina. The writer of this review reported a 
successful operation some years since. 

Vaginismus is very fully considered. Forcible dilatation is referred to in 
the therapeutics, " as proposed by different authors, Charrier, Horwitz. Courty. 
and Sutugin." The earliest of these references is 1868. But Michon* had 
operated by this method in 1859, and by incision in 1847. 

' Gazette Medicale, 1869. 

2 Traite des Fistules uro-genitales de la Femme, Paris, 1870. 

' Bulletin General de Therapeutique, August 30, 1S61. 



1876.] Wilson, Lectures on Dermatology. 2-41 

We are informed tbat " in America, ethereal cohabitation has been intro- 
duced as a means of cure for vaginismus, that is, the wife is anajsthetized, and 
while she remains in a state of narcotism the husband performs coitus, with a 
view of inducing conception, in order that recovery may l)e brought about by 
parturition." If ethereal cohabitation is a recognized practice in America, it 
is unknown to us, and we do not l)elieve it to be so. The only foundation for 
such a statement' is its employment, it is said, in a single case by some one who 
is unknown to fame. 

Schr(L>der rejects in this disease the various operations with the knife devised 
by Burns, Sims, and others, as well as abrupt dilatation, but relies upon gradual 
dilatation with a series of cylindrical specula. 

Rapture of the perineum is fairly, but too briefly, considered, and excellent 
diagrams with a description of Simon's operation given. 

Coccygodynia is the last subject in the volume. We regret that Schrceder 
or any one else should prefer this term to the briefer and more euphonious 
designation coccyodynia. first used, if we mistake not, by Sir James Simpson ; 
the genitive case is not so necessary of expression in forming a compound 
word, that it should be insisted upon. 

In concluding this notice, we again desire to express our high appreciation 
of Schrceder on the Female Sexual Organs, as a most valuable contribution to 
gynaecology, by no means calculated, however, to supersede the works of 
'I'homas and of Barnes, possessing too little of a clinical character, too defi- 
cient in details, especially in the diagnosis and treatment of many of the 
commoner forms of the disease, to be as complete and satisfactory a guide as 
either of these. T. P. 



Art. XXVIII. — Lectures on Dermatology, delivered in the Royal College of 
Surgeons of England in IS14:. IS15, including Struma ; Lupus; Lympha- 
clenoma ; Xanthoma; Epithelioma; Ichthyosis; Scleriasis ; Verruca; 
Clavus ; N'wous ; Spargosis ; Molluscum ; Chcloma ; Prurigo. By Erasmus 
Wilson, F.R.S., F.R.C.S., Member of Council, and Professor of Derma- 
tology. 8vo. pp. 224. London : J. & A. Churchill, 187.5. 

The volume before us consists of twelve lectures, and forms part of a series 
of discourses illustrating the beautiful collection of models which Mr. Wilson 
presented, some five years ago, to the College of Surgeons. The plan of in- 
struction, embracing a full description of all the more important models, 
together with general remarks upon the subject, and the histories of similar 
cases which have come under the lecturer's notice, has proved entertaining as 
well as instructive. The diseases which receive attention include several about 
which considerable diversity of opinion exists, and it is to these that we shall 
in the present notice invite particular attention. 

Under the head of " atrophic diseases" Mr. Wilson places strife atrophicae, 
morphcea, and scleriasis, three conditions which of late have been the theme 
of much discussion. Our knowledge of the two latter especially, morphoea and 
scleriasis, is but vague and extremely unsatisfactory, due in part to the inac- 
curate manner with which the reported cases have been studied and described, 
and in part to the rarity of their occurrence. Any reliable clinical information, 



' Sims' Uterine Surgery, p. 33L 

No. CXLL— Jan. 1876. 16 



243 Bibliographical Notices. [Jan. 

therefore, concerning these disorders, must be regarded as valuable contribu- 
tions to literature. 

Mr. Wilson describes, as follows, the stris atrophicse, which he remarks may be 
very properly denominated idiopathic or spontaneous cicatrices. " "Without any 
evident cause of injury to the skin, these cicatrices make their appearance as 
gently curved and undulating lines on different parts of the body, and, as far as 
the age is concerned, are hardly to be distinguished from cicatrices resulting 
from loss of substance of the integument. A closer examination will detect that 
they are softer and more flexible than cicatrices resulting from wounds, and 
have a semitranspareticy and lustre which are suggestive of mother-of-pearl. 
They have none of the induration resulting from excess of white fibrous tissue, 
which is often discoverable in true cicatrices, and consequently exhibit no ten- 
dency to the formation of cheloma." The cause of these lesions is regarded 
as being twofold, namely, pressure and feebly-nourished and feebly-organized 
tissue. Except in the case of the strise which occur in pregnancy, and similar 
conditions of cutaneous distension, it has always appeared to us that pressure 
has had but little share in the production of these peculiar formations; their 
presence being attributable rather to a local atrophy or degeneration of the 
skin than to mechanical agencies. Following the brief and accurate description 
just quoted are to be found the reports of several cases, together with remarks 
relating to the several varieties of linear atrophy. 

According to Mr. Wilson the transition from linear atrophy to raorphcea is 
manifestly clear. Morphoea and scleriasis (scleroderma) are now considered 
together, the various views of writers on these diseases being presented. Three 
varieties of scleriasis are made, as follows : the diffused, the circumscribed or 
morphcea (identical with the keloid of Addison), and a third, severe, incurable 
variety, of which the following case is an illustration. The patient was a gen- 
tleman aged 54, by profession a secretary, who suffered from an affection of the 
hands and breast. He was thin, his face emaciated, features anxious, and the 
skin dry, yellowish, and stretched, as though adherent to the structures beneath. 
The hands were cramped in appearance, the fingers bent, the knuckles red and 
swollen, resembling chillblains, and sometimes painful, whilst the internodial 
portion of the fingers was small and contracted. The whole of the affected 
skin was hard to the touch, and smooth, looking more like horn than flesh, and 
the lines of motion were obliterated. The appearance of the hands was sug- 
gestive of a stagnation or interruption of the circulation, and to the patient 
they felt f.uU and distended. He complained of inability to maintain the tem- 
perature of the hands and of difficulty in picking up objects. The right hand 
was more severely afilicted than the left, and the first two fingers of the left 
hand more than the rest. Here and there there were corns in the epidermis, 
and the nails were ribbed longitudinally and transversely, marking their surface 
into small square areas. The backs of the fingers were deeply pigmented, of a 
dark-brown colour, the pigmentation extending to the middle of the hands ; 
beyond this line the skin was bleached and around the wrist resumed its deep 
pigmentation. The affection of the hands began three years ago, with occa- 
sional swelling, the stiffness and hardness following some months later. On 
the upper part of the chest the skin had undergone a similar change ; it was 
firmly adherent to the sternum and pectoral muscles, was hard and contracted, 
and had drawn the shoulders forwards, narrowing the chest. The skin here 
was partly leucodermic and glazed, and partly hypera>mic, the hyperfemic 
portions being segments of circles which originally formed the boundary of the 
whitish patches. Tbere was likewise a hard and raised ridge stretching across 
the forehead, which produced a sensation of tightness. His neck was deeply 



1876] Wilson, Lectures on Dermatology. 243 

pigmented with u brown discoloration, in the midst of which were numerous 
white and dense spots of scleroderma of small size. The rest of the skin pitted 
easily on pressure. 

The patient stated that the disease began three years before by swelling of 
the hands, which was repeated from time to time ; some months later the hard- 
ness and contraction came on, and subsequently pains in the joints and tingling 
in the affected skin. Next in order he noticed the affection of the chest. The 
trouble about the neck was usliered in by stifl'ness and difficulty of raising the 
chin. He also complained of a slight impediment in swallowing. This general 
condition was marked by fulness, weak voice^ stiffness of limbs, and pains in 
the joints, particularly the hips and knees. He likewise experienced a tin- 
gling sensation in the skin. He had previously taken arsenic, mercury, warm 
sea-baths, and sulphur baths, with no beneficial result. Under Mr. Wilson's 
care he had taken small doses of arsenic, iron, quinia, strychnia, and other 
medicines. Locally he had used frictions with stimulating liniments, which had 
to be discontinued on account of excessive stimulation to the skin. In 1870 
superficial ulcerations over the malleoli of the right foot made their appear- 
ance ; in 1871 the knuckles of the hand suffered in the same manner. In 
1873 he was reported pretty well, but extremely sensitive to the cold, with 
great uneasiness in the hands attended with sensations of pricking and burning, 
as though with a hot iron. The fingers now became more crooked and were 
seldom free from excoriations and superficial ulcers. When the ulcers healed, 
a hard cicatrix formed, which broke down into ulceration. Increased difficulty 
in deglutition was now complained of; also constipation. In 1874 the left foot 
was attacked like the right, with considerable congestion and fulnes? of the 
toes. Nervous symptoms now also supervened. The gentleman died in the 
spring of 1875. 

Mr. Wilson concludes his full and elaborate report of this remarkable and 
very rare case by drawing special attention to its slow and progressive course. 

Several cases of morphoea are next described, the pathology of which dis- 
ease is considered to be a fibrous transformation of the structure of the skin 
with atrophy ; otherwise a fibroma iv/th atrophy, or fibrous degeneration of 
the skin. The last of the cases of morphoea (so called by Mr. Wilson), ap- 
pears to us to be a case of the disease so fully described by Lande under the 
name of " L'Aplasie Lamineuse progressive (Atrophic du tissu connectif), celle 
de la face en particulier," which disease certainly possesses many features very 
different from morphoea. Concerning the treatment of these atrophic conditions, 
we learn that the remedies most likely to prove of benefit are arsenic, quinia and 
iron, iodide of iron, phosphorus, uitro-hydrochloric acid with bitters, and the 
corrosive chloride of mercury. To these must be added the hygienic assist- 
ance of food, exercise, and air. Locally, saponaceous ablutions, the Turkish 
bath, and frictions are regarded as especially useful. 

In the consideration of the treatment of cheloma (keloid) Mr. Wilson 
states that he has obtained the best results from the use of a solution of one 
drachm of iodide of potassium, with an ounce of soft soap and the same 
quantity of spirit of wine. This should be painted on the growth and covered 
with lead plaster spread on a soft piece of leather, the dressing not to be re- 
moved for a week, and only to be replaced by another of the same kind. Mr. 
Wilson adds that he has known keloid to have been cured by this treatment, 
and considers it to be the only plan which offers any real prospect of amend- 
ment. 

Under the " neuropathic affections," the last class in the present series of 
lectures, are to be found the reports of several exceedingly interesting and 



244 Bibliographical Notices. [Jan. 

rare cases, which the lecturer designates as " neurotic excoriations." In these 
cases there is pruritus, often severe, at other times slight; there is a pro- 
minence or broad papule, caused by infiltration and congestion, which is the 
ordinary seat of the pruritus ; and, moreover, there is a special tendency on 
the part of the skin to excoriate and bleed. The application is obstinately 
persistent, and is accompanied by pigmentation and decided irritability and 
debility of the nervous system. Mr. Wilson continues by remarking that 
this f)eculiar affection has been under his careful observation for years, and 
that in describing it, it is necessary to divide the cases into two groups, one 
dependent on general functional debility and defective sanguification, and the 
other due to a weak and irritable state of the organic nervous system, such as 
constitutes the basis of hysteria. The symptoms of this disorder are of so 
singular a character that we venture to present a brief abstract of one of the 
cases. A maiden lady, set. 47, had her face spotted over with small abrasions 
from which the epidermis had been recently removed, the excoriations being 
oval or polyhedral in shape, and about a quarter of an inch in length. Fifteen 
or twenty of these lesions were scattered over the face, but only some three or 
four of these appeared fresh; the rest were in the stage of decline. The 
patient's attention was first directed to their existence by a sensation of fulness, 
burning, and tingling, this sensation continuing for hours, until, indeed, she 
was driven to seek relief by scratching. The epidermis was readily detached, 
which seemed to slide off the spot and bring to view the excoriated patch, 
attended by more or less bleeding. 

Mr. Wilson explains the pathological history of the affection by remarking 
that " at first there is a hyperaemia, which gives rise to a flat, circumscribed 
induration, accompanied with slight redness, and with the sensation of fulness, 
burning, and tingling ; a slight serous exudation beneath the horny layer later 
taking place and loosening the epidermis." 

The process in the case just reported was a chronic one, having lasted for 
two years, in the form of successive series of lesions, which were at no time 
altogether absent. More or less distinct pigmentation followed the healing of 
each excoriation, which was very slow to leave the skin. The lady was of 
decidedly nervous temperament; was shy, dejected, silent, and desirous of 
shunning observation. She complained of pains in the head, of exhaustion 
and debility, and had a weak pulse. Careful examination and investigation 
precluded the possibility of the case being in any way connected with ma- 
lingering. 

The termination of the disease is not stated. 

The limited space at our command forbids entering upon any discussion of 
the remaining diseases; we must, therefore, refer those who desire further 
information to the volume itself. The book, in our estimation, is the most 
'nteresting one of the series. L. A. D. 



Art. XXIX. — A Prnctical Treatise on Fractures and Dislocations. By 
Frank Hastings Hamilton, A.M., M.D., LL.D., Surgeon to Bellevue Hos- 
pital, New York, etc. Fifth edition, Revised and Improved, Illustrated with 
344 wood-cuts. 8vo. pp. xxiv., 807. Philadelphia : Henry C. Lea, 1875. 

Dr. Hamilton's work has been repeatedly noticed in the pages of this Jour- 
nal, and is too firmly established in its position as an acknowledged authority 
to need the aid or fear the criticism of a reviewer. What has been said of it 
before is still true, and it is only necessary to refer here to the few points in 



1870.] Hamilton, Treatise on Fractures and Dislocations. 245 

which this edition dilTors from those which have gone before it. The number 
of illustrations has been raised to three hundred and forty-four, an increase of 
twenty-two, while the size of the volume is not materia41y enlarged. 

Among the most interesting portions of the book, are the opinions of its 
author in regard to the treatment of fractures of the femur with the immova- 
ble apparatus in vogue on the continent of Europe, and of late years largely 
adopted at Bellevue Hospital in New York. A comparative table is given, 
which presents the results of tliirty cases treated by the Mathiessen plaster 
of Paris method, and twenty-four cases in which extension by a weight and 
coaptation of fragments by lateral pressure was the plan adopted. 'I'rouble- 
some anchylosis of the knee, paralysis and even gangrene, with an average 
shortening of }g of an inch are noted by Dr. Hamilton as among the results 
of the treatment by the immovable apparatus, while the twenty-four cases 
treated by the older plan had an average of but /^ of an inch shortening with- 
out unpleasant complications. 

Although these statistics go to confirm the opinion of the reviewer that the 
treatment by fixed bandages is not suited for the early stages of simple frac- 
tures, the numbers are too limited to carry conviction, and it will require a 
larger series of carefully observed and classified cases, attended with bad 
results, to condemn a practice adopted by so many men of eminence and expe- 
rience. The results obtained in these cases are so generally favourable when 
simple extension, with short thigh splints or sand bags is practised, that it is 
difficult to understand why a doubtful method should be tried, when the only 
object gained thereby is the avoidance of a few weeks spent in the recumbent 
position, which in the majority of cases does no harm. In those cases where 
the impairment of health induced by the enforced confinement maybe of grave 
importance, the fixed plan will afford a valuable alternative. 

Every practical surgeon is aware of the danger attendant upon tight band- 
aging immediately after a fracture, and is familiar with the shrinkage which 
occurs in a bandaged limb; now it would appear that either a dangerous 
amount of pressure must be used when the apparatus is first applied or, pru- 
dential motives ruling, the bandages will be so loosely put on as to necessitate 
their early removal and reapplication, when the method is no longer the immova- 
ble one. In the face of these facts it seems unwise to run the risk of a firm 
unyielding bandage, which the immovable variety should be, at any rate during 
the early stages of a fracture where the accurate coaptation of the fragments 
is a matter of little moment. Later on in the treatment, when tolerance of 
pressure is acquired and the parts must be kept in accurate apposition, the 
modern plaster dressing is doubtless a great improvement upon the old forms 
of fixed apparatus, with which, as pasteboards, starched bandages, etc., the pro- 
fession has been long acquainted, yet the femur does not seem to be the best 
bone on which to demonstrate the advantages of this treatment. 

In compound fractures, however, especially in those of the leg, Dr. Hamilton 
has found the plaster-dressing of great advantage, and here, from the immova- 
bility obtainable which is so important an indication, and the facility with 
which dressings can be applied and discharges removed through windows cut 
in the bandage, there can be no question as to the value of this mode of dress- 
ing ; most practical surgeons will agree with Dr. Hamilton in endorsing the 
practice, and will welcome the fixed apparatus as a boon in these troublesome 
and ofttimes serious cases. 

This book will attract many by its wealth of illustration, and will be found 
to contain almost everything of value relating to its subject-matter which has 
made its appearance up to the present time. S. A. 



246 Bibliographical Notices. [Jan. 



Art. XXX. — A Treatise on Human Physiology ; designed for the Use of 
Students and Practitioners of Medicine. By John C. Daltox, M.D., Pro- 
fessor of Physiology and Hygiene in tlie College of Physicians and Surgeons, 
New York, etc. Sixth edition, revised and enlarged. AVith 31G illustrations. 
8vo. pp. 825. Philadelphia : Henry C. Lea, 1875. 

A Text-Doolc of Human Physiology ; designed for the Use of Practitioners 
and Students of Medicine. By Austin Flint, Jr., M.D., Professor of Physi- 
ology and Physiological Anatomy in the Bellevue Hospital Medical College, 
New York, etc. Illustrated by three lithographic plates, and 313 wood-cuts. 
8vo. pp. 978. New York : D. Appleton & Co., 1876. 

Prof. Dalton's work has been so long and so conspicuously before the medi- 
cal public, and has been so often reviewed iu the pages of this Journal, that it 
no longer requires any extended notice at our hands. Its success is amply 
shown by the fact that the fifth edition, which appeared in 1871, has been 
exhausted in the short space of four years. In its present form the work has 
been considerably enlarged. Nearly one hundred pages and thirty-two illus- 
trations have been added. Many portions have been re-written, and as the 
pages have been enlarged by a new typographical arrangement, the matter of 
the volume has been increased at least fifty per cent. That part, in the section 
on nutrition, devoted to the consideration of the physiological chemistry of the 
solids and fluids of the organism, has been extensively revised. New facts 
concerning the proximate principles composing the human body have been 
introduced, while the advanced views now held as to the relation of these prin- 
ciples to each other in the process of nutrition are concisely and clearly stated. 
An entire chapter has been appropriated to the description of the colouring 
matters, which in the preceding edition were dispatched in a page and a half; 
and a new chapter has been introduced treating of lecithine, cerebrine, leucine, 
and other crystallizable nitrogenous substances. The chapter on food has 
also been altered and considerably extended. The description of the function 
of digestion has not been much changed, though several new illustrations have 
been introduced into this portion of the work. In view of the remarkable facts 
collected by Darwin in his recent work on " Insectivorous Plants," our author 
is scarcely warranted, we think, in asserting, as he does in this, as well as in 
the former editions of his work, that the digestive " process does not occur in 
vegetables." A noticeable defect in previous editions of Prof. Dalton's 
Treatise is still apparent in the one now under consideration. The important 
and very complex, though quite well understood processes of mastication and 
deglutition are passed by unnoticed. The student looks into Dr. Dalton's pages, 
in vain, for any description of the mechanism of these acts. 

In the chapter upon the bile much new matter has been introduced in the 
form of a description of the minute anatomy of the liver, and -an account of the 
optical properties which are exhibited by the bile. The spectral analysis of 
the animal fluids has lately been assuming so much importance, that we recom- 
mend to our readers the perusal of Dr. Dalton's remarks on the subject, in the 
volume under notice, embodying as they do the results of our author's special 
investigations upon this subject. 

A brief account of the spectral analysis of the blood has been added to the 
chapter which treats of that fluid. In this chapter we find the following judi- 
cious remarks upon the differential diagnosis, between human blood and that of 
animals : — 



187r..] Dalton, Flint, Human Physiology. 2i1 

" If a blood stain, accordingly, which in a watery solution gives the common 
spectrum of hemoglobine, be found to contain oval nucleated globules, this 
would show it to be the blood of a bird, reptile, or fish; and the oval form 
alone would show that it is not human blood. The (lucstion, therefore, whetiier 
a particular specimen be composed of human blood may often be decided with 
certainty /// (he in'ijalice by microscopic examination. But if the specimen 
contain circular globules, without nuclei, it will be impossible to say positively, 
in any instance, that they belong to human blood, and not to that of some 
animal, such, as the ape or the dog, whose red gloliules nearly approach the 
human in size. In most of the domesticated quadrupeds, the jilobules are 
smaller than in human blood; but in both the sloth and the elephant, they are 
larger. If it were only required to decide whether a given specimen of fresh 
blood belonged to man or to the rausk deer, for example, or even to the goat, 
no doubt the difference in size of the globules would be sufficient to determine 
the question. 

•' But within nearer limits of resemblance it would be doubtful, because the 
size of the red globules varies to some extent in each kind of blood ; and in 
order to be certain that a particular specimen were human blood, it would be 
necessary to show that the smallest of its globules were larger than the largest 
of those belonging to the animal in question, or vice versa. The limits of this 
variation have been tolerably well defined for human blood, but not sufficiently 
so for many of the lower animals to make an absolute distinction possible. 

"In the examination of stains or blood spots, the difficulty is increased by 
the fact that the drying and subsequent moistening of the globules introduces 
another element of uncertainly as to their exact original size." 

In the chapters on respiration and calorification, the chemical changes in 
the respired air and in the blood, and the mode of production and regulation 
of animal heat have been more elaborately discussed than in former editions of 
Prof. Dal ton's work. Several pages descriptive of the anatomical structure 
and arrangement of the lymphatic system have been introduced into the chapter 
which treats of the physiology of this portion of the organism. 

In the fifth edition of his work. Prof. Dalton devoted an entire chapter to 
the function of secretion. This chapter has been left out of the present edition, 
ranch to the disadvantage, we think, of the student, who would have looked in 
vain for any account of the lachrymal, sebaceous, meibomian, cernminous, and 
other secretions. Mucus is briefly alluded to under the head of albuminous 
proximate principles, milk in the article on food, and perspiration as a means 
of regulating animal heat. This is certainly a defect which should be remedied 
in the future issues of the work. 

The chapter on the urine has been extended and revised. It is, however, in 
the section devoted to the nervous system and the special senses that the 
greatest changes and additions of new material have been made. Within the 
past few years investigations in the field of nervous physiology have been 
pushed forward with extraordinary activity. Many new facts of a remarkable 
character have been discovered, and the views once held of the action of the 
nervous system have been largely modified. Prof. Dalton has accordingly 
made many judicious alterations in his description of the structure, properties, 
and mode of action of the brain, spinal cord, ganglionic system, and the cranial 
and spinal nerves. About 267 pages, or one-third of the entire work, are occu- 
pied with the consideration of this subject. 

With the exception of some additional remarks upon the origin of plants 
and animals, upon spontaneous generation, and upon the successive stages of 
the development and differentiation of the blastodermic membrane, the section 
on reproduction remains substantially the same as in former editions. 

In the present issue of his " Treatise" our author has adopted the new chemi- 
cal notation and nomenclature, and the centigrade system of measurements for 



248 Bibliographical Notices. [Jan. 

length, volume, and weight; while temperatures are given in degrees of the 
Centigrade scale, usually accompanied by the corresponding degrees of Fahren- 
heit's scale, inclosed in brackets. It would have been more consistent and 
certainly more advantageous, by facilitating the reading of the student, if the 
foreign measurements of length, etc., had also been accompanied by their 
English equivalents. Very few students and practitioners are able, at sight 
and without calculation, to obtain an adequate idea of the weight, volume, or 
length of bodies when expressed in terms of the decimal system. By placing 
the equivalent figures side by side, in all cases in which such measurements 
are referred to, the student is gradually and insensibly taught to appreciate 
correctly foreign metrical expressions. 

We turn now to a brief examination of Prof. Flint's Text-booJc of Human 
Physiology. This is simply an abridgment or condensation of the author's 
larger work recently completed in five volumes, and from time to time fully 
analyzed in former numbers of this Journal. "While, on the one hand, the 
numerous bibliographical citations and historical references contained in the 
larger work have been excluded from the " text-book," on the other, many ad- 
mirable illustrations have been introduced, derived, for the most part, from the 
works of Sappey, Haeckel, Robin, Marey, Dalton, Woodward, and other foreign 
and domestic authors. The introduction of so many well-executed wood-cuts 
and plates serves to lighten the labour of the student, by illustrating ihe text, 
and thus enhances very materially the educational value of the work. 

In turning over the pages of Prof. Flint's " Text-book," we notice that more 
has been done in the way of condensation than of revision of the material of his 
Physiology of Man. In the former work the frequent repetitions which need- 
lessly increased the size of the latter have been avoided, some additions have 
been made, and certain changes of opinion expressed. These additions, how- 
ever, have been too few to materially change the work. It is not, therefore, 
necessary to present our readers with an analysis of its contents. SufiBce it to 
say, that we consider the work to be an important addition to American medi- 
cal literature, and cordially commend it to both students and practitioners as 
a valuable manual of the science of physiology. J. A. M. 



Art. XXXI. — Vision: its Optical Defects and the Adaptation of Spectacles. 
Embracing, First, Physical Optics; Second, Physiological Optics; Third. 
Errors of Refraction and Defects of Accommodation, or Optical Defects of 
the Eye. With Seventy-four Illustrations on Wood, and Selections from the 
Test-Types of Jaeger and Snellen. By C. S. Frnner, M.D. 8vo. pp. 299. 
Philadelphia : Lindsay and Blakiston, 1875. 

In proposing to give to a work on pliysiological optics, and the errors of 
refraction and accommodation, " a concise and popular yet comprehensive 
form," the author has set himself a most difficult task, which he has partially 
succeeded in accomplishing. A scientific book which adds absolutely nothing 
to the existing stock of knowledge on the subjects of which it treats, has no 
other " raison d'etre" than its claim to teach systematically and clearly what 
is already known ; and Dr. Fenner's book must be judged entirely by this 
standard. 

The subject is divided into three sections : First, physical optics ; second, 



1876.] Fenner, Tision. 249 

physiological optics ; tliiiil. errors of refraction and defects of accommodation, 
or the o|)tical defects of the eye. 

The first is a concise and elementary summary of the laws of light, the 
emission and wave theories, the formation of images, the various phenomena 
of prismatic colours, etc., and is well adapted to interest the general reader, 
or even to instruct the beginner. 

So far as the arrangement of its material is concerned, part second is not so 
satisfactory; while less than a page is devoted to the "anatomical construc- 
tion of the eye." about half a page to the simplified diagrammatic eye of 
Listing, and two or three pages to the ophthalmoscope, some five pages are 
taken up by an apparently purposeless introduction of al)struse dioptric 
calculations transferred from the appendix of the great work of Donders, where 
they appear in '-small print" for the benefit of " only those who wish to pene- 
trate more deeply into the subject." The general reader is not likely to 
exercise his brain with these triangles and equations, but, if he does, he will 
find at the end that his calculations have taken liim no further than the cornea, 
and that his hard-earned knowledge is applicable only to the aphakial eye. 
Generally, however, the selections from Donders and Helmholtz, of which this 
section largely consists, are judicious, and the first two-thirds of the book form 
an excellent popular treatise on physiological optics; indeed, we know of no 
other one work from which a general knowledge of the subject can be obtained 
so readily. 

The third section explains the nature of the various optical defects of 
vision, and gives directions for detecting and correcting them ; in short, is a 
kind of " hand-book" of refraction and accommodation. The subjects of 
presbyopia, hypermelropia, and myopia are well handled, but the directions for 
treating astigmatism are wanting in system and precision, and are strangely at 
fault in leaving the student to suppose that the principal meridians of curvature 
are always vertical and horizontal. So far from this being the rule, it is almost 
exceptional, and the exact determination of the inclination to be given to the 
axis of the cylinder is often the most difficult part of the correction. Many 
patients are extremely sensitive to a variation of the axis of even a few 
degrees. 

An appendix is added, containing general instructions for the selection of 
glasses, for the benefit of persons situated beyond the reach of competent 
professional advice. Test types are furnished for the use of such persons, but 
trial glasses must be supplied from the spectacle dealer's stock, and, unless 
the " opticians" of the smaller towns have a more modest appreciation of their 
scientific attainments than their brethren of the cities, there will be difficulties 
in the way of carrying out the plan of every man his own optician. 

With the facilities now afforded at the better medical colleges for acquiring 
some practical knowledge of ophthalmic surgery, there is no good reason why 
anyjjractitioner of modern date should not be a safer guide than either the 
patient himself or the dealer. 

In conclusion, we can congratulate the author on having realized the hope 
expressed in his preface, that his volume might '-give much usefulinformation 
to the student, the physician, and to those of the general public who desire to 
obtain an insight into this department of science." 'J'he author's style is 
correct and clear, and the publisher's work is unexceptionable. An oversight 
in proof-reading is met with only now and then, the most marked one is the 
repeated occurrence of the plural noun " phenomena" with a singular verb. 

G. C. H. 



250 Bibliographical Notices. [Jan. 



Art. XXXII. — The Relations of the Nervous System to Diseases of the Slcin. 
ByL. Duncan Bulkley, A.M., .M.D., Physician to the Skin Department, De- 
milt Dispensary, New York, etc. etc. Reprinted from the Archives of Elec- 
trology and Neurology. New York : G. P. Putnam's Sons, 1875. 

In this brochure, Dr. Bulkley has given a valuable contribution, relating to 
the various cutaneous disorders which are more or less intimately connected 
with the nervous system. As yet but very little is definitely known concerning 
the extent to which the nervous system is directly involved in the production 
of diseases of the skin ; in some affections, as for example, herpes zoster, and 
the functional neuroses, there is no doubt that the chief disturbance is prima- 
rily with the nerve trunks, or filaments, while in other diseases, as eczema, it is 
extremely difficult to arrive at any conclusions respecting the part which the 
nervous system takes in the production of the lesions. 

It is just to points of this character that the writer of the article under con- 
sideration calls the attention of the profession, and we think (not unmindful that 
the subject is a difficult one to deal with) in a highly satisfactory and credit- 
able manner. 

The distribution of nerve elements in the normal cutaneous tissues, is first 
referred to, in which description it is shown to what extent the skin is supplied 
with these sensitive and delicate structures. A number of the more important 
recent anatomical discoveries in this field of study are very clearly and suc- 
cinctly set forth. 

Physiological inquiries are next entered upon; the mode of production of 
skin lesions through nerve influence, whether by the vaso-motor nerves or by 
the action of special trophic nerves, receiving careful investigation. Reflex 
nerve influence is also dwelt upon at lenuth, and numerous interesting cases 
cited, showing how frequently many and varied aff"ections of the skin are asso- 
ciated with and dependent upon causes which must be placed under this head. 

The pathology of the subject receives notice, and is perhaps the most inter- 
esting portion of the monograph. Here are to be found the reports of cases . 
in which the skin aff'ection was found to be consequent upon peripheral wounds 
of nerves ; attendant upon lesions of conducting nerves ; due to brain or spinal 
disease ; or to idiopathic nerve lesions found post-mortem in nerves supplying 
diseased skin. 

The conclusions which Dr. Bulkier' arrives at are ; that although the nervous 
system has much to do with the causation of skin diseases, in the present state 
of our knowledge, it is impossible to say that certain disorders are neurotic and 
others not. Individual cases may be said to be neurotic, but further than this we 
cannot go. For, when we attempt to construct a class of neurotic aff'ections 
from the stand-point of pathology, we find the number of diseases whicli^are 
caused or influenced by nerve disorders so great that it is impossible to draw 
the line without including a host of dissimilar diseases. 

The article is both suggestive and interesting, and we trust will be the means 
of directing attention to the value to be derived I'rora recorded observations in 
this department of medicine. L. A. D. 



1876.] Report into the Sanitary Couditioii of the Schools. 251 



Art. XXXIII. — Report of the Committee appointed h if the Board of Public 
Edandiun to Inquire into the Sanitarf/ Condition of the Schools of the First 
School District of Pennsylvania, City of Philadelphia. Pamphlet, pp. 37, 
witli 7 plates. Thiladelphia, 1875. 

This very modest little pamphlet presents facts of startling significance, and 
suggests reflections of the gravest import. The inquiry was made at the sug- 
gestion of the Social Science Association of Philailelphia. The Board deserves 
credit for the honesty and fearlessness with which it has ascertained and stated 
truths all-important of recognition, but by no means agreeable of confession. 

Two series of questions were prepared by the Committee. One, addressed 
to teachers, elicited replies from over four hundred schools of all grades. The 
other, addressed to such physicians as could give time and the requisite ability 
to the investigation, received from a dozen physicians, answers as to forty-four 
schools. Both sets of returns are here tabulated on half a dozen large folded 
sheets. A very few pages of the briefest and most practical comment upon 
the tables compose the general Report of the Committee. This exhibits an 
intelligent appreciation of existing evils, and an earnest desire to procure their 
removal. 

Desiring to obtain data as to atmospheric impurities which should be thor- 
oughly trustworthy. Dr. Nebinger, of the Committee, employed a practical 
chemist to examine the air of a dozen specimen school-rooms of different 
grades. The report of this gentleman, Mr. E. Thomson of the Boys' High 
School, forms the text for some sensible remarks by Dr. Nebinger, upon the 
effects of so high a degree of impurity ; and upon the manner in which exist- 
ing flues, in many school buildings, might be made to discharge, at least in 
part, the functions for which they were designed but which they have failed to 
perform. 

Remarks and suggestions not capable of tabular expression, are printed, as 
made by two of the medical reporters. 

A general summary of the reports of chemist and physicians, tabular and 
other, prepared at the request of the Committee, attempts to exhibit at a glance 
such of the results obtained as could, perhaps, be best interpreted and com- 
mented on by a medical man. 

Now we wish to direct attention to one fact, that while other evils are more 
or less frequent, or important, or distinctly recognizable, the one great evil of 
poiso.vED AIR is everywhere and by all recognized and deplored as a cause of 
sufi'ering and disease. Thus out of two hundred and fifteen primary schools, 
only four or five (including some indistinct answers) neglect to state that 
open loindozvs are necessary and habitual. And though about one teacher in 
ten, in these schools, claims to be able to '• maintain a tolerably pure atmo- 
sphere, warm enough, by any means," — this testimony, dubious as it is, is often 
contradicted by the thermometric report, which shows a stratum of cold air 
near the floor. Of sixty grammar schools, all but one mention the necessity 
of open windows. 

Reflect for a moment on the frightful enforced exposure to the causes of 
croup, pneumonia, and other diseases, which is here shown to be the sole and 
chosen refuge from blood-poisoning. A man in his office, can open a window 
and avoid the draft, or put his feet to the fire. These poor children must sit 
in chairs screwed to the floor, and take furnace blight and wintry blast just as 
they come ! 



252 Bibliographical Notices. [Jan. 

Nor are the direct drafts of cold air alone, liable to cause chills and conse- 
quent inflammation. For instance, 263 girls, in a school with air "extremely 
foul," " no ventilation," " windows open," and the mercury outside at 20'^ F., 
■were, studying at a temperature of 52° near the floor and only 58° seven feet 
above. And again, in like circumstances, we find 364 girls, with open windows, 
temperature outside at 20°, and within, 58° and 64°. Two schools presented 
the cheerful temperatures of 40°, near floor, and 50°-52° above. These cases 
are not selected as the very worst, but such as happened to meet the eye. 

The chemical reports are not much more cheerful reading. They show uni- 
formly increased, but very different, percentages of carbonic acid. This, of 
course, is considered important, more as a measure of other and more baneful 
organic matters than for its own qualities. The highest percentage noted by 
the practical chemist, was .21 of one per cent. A much higher amount was 
reported by another observer. 

We must admit then that our schools are unventilated. Open windows are 
necessary all or nearly all of the time. Yet many of them have " flues," and 
" registers," and various appliances intended by the builders to remove foul air. 
A sad proof of the utter lack of practical knowledge concerning a subject of 
supreme importance to the health and life of a great people ! 

Another evil connected with our schools which would seem very great, if not 
overshadowed by the giant vice just described, is the faulty arrangement of 
windows and desks with reference to the eyes. Visual hygiene has been wholly 
ignored in the location and construction of these. Pupils are often obliged to 
study with a glare of light in front of them, from books either too near the eyes 
or too remote. There is no doubt that much of the increasing prevalence of 
visual weakness and defect may be due to this cause. Indeed, eye troubles 
would seem to be often directly traceable to school life. 

Badly formed desks and seats are also, doubtless, chargeable with much 
needless fatigue and exhaustion, besides preventing proper expansion of lungs 
and producing distortions and curvatures. 

Privies so offensive as to contaminate the air of adjacent school-rooms, are 
in several cases reported. 

Undrained cellars, full of dampness, and even stagnant water, are not unfre- 
quently reported. This condition of things is fraught with danger to the health 
of pupils in the lower rooms. 

Inquiry as to the use of light gymnastic exercises frequently elicits the reply 
that desk.s and pupils are too numerous and crowded to admit of these. We 
believe the employment of a few moments in each hour in gentle physical exercise 
is an important agency in preserving the health of school children. The natural 
restlessness of childhood, which cannot safely be wholly repressed, may thus 
get proper vent, while great or protracted determination of blood to the brain 
is avoided. 

We cannot but wish that sanitary inspection of our schools could be made 
general, constant, an ] systematic. Not information only, but reformation of 
abuses might then be expected. A physician who should also be an accom- 
plished chemist, and acquainted with sanitary science, properly paid for 
devoting his whole time to the work, and clothed with proper authority, could 
immensely benefit the rising generation in our schools. Some such suggestion 
is, if we remember rightly, made in the recent report of the Board of Health of 
Philadelphia, and is worthy of serious attention. If kept wholly free from the 
contamination of politics, carefully and wisely made, and earnestly supported, 
such an appointment should be productive of incalculable good. 

Whatever course the educational authorities may see fit to pursue, we 



1876.] Ileallh-Board Reports. 253 

earnestly trust that they will realize the momentous responsibilities resting 
upon them. The report of their committee is before them. The sad facts 
which it reveals cannot be ignored. Let the medical profession in Philadelphia, 
and let all intelligent men and women, resolve so to inform and arouse public 
opinion that sanitary reform in the schools shall be demanded in tones admit- 
ting of no denial and no delay. 

We had designed adverting to several papers upon school hygiene in various 
reports which are before us. Space forbids, however, anything more than the 
statement that, all over this land, thoughtful men are awakening to the evils 
and perils of e.xisting schools. Health reports of Michigan, California, Massa- 
chusetts, and the cities of New York and Boston, have recently presented im- 
portant essays on the subject. B. L. R. 



Art. XXXIY.— Health-Board Reports. 

1. Report of the Board of Health of the City and Port of Philadelphi a 

for 1874. 8vo. pp. 402. 

2. Second Annual Report of the Secretary of the State Board of Health of 

Michigan. Fiscal year ending Sept. 30, 1874. 8vo. pp. xxxiii.. 221. 
Lansing, 1875. 

1. Like most issues of this kind, this report exhibits an annual growth some- 
what appalling to the reviewer. It exceeds its predecessor, noticed in this 
Journal for October, 1874, by one hundred and fifty pages. 

It will be impossible for us to advert to every point of interest in this very 
full and satisfactory report. AVe can only glance at one here and there, and 
recommend to every physician, and every intelligent friend of social science, a 
careful examination of the entire work. 

As to the statistical results here presented, the most gratifying is the low 
rate of mortality. This, for 1874, is 19.66 for every thousand persons living. 
It is the lowest rate for fourteen years ; the average having been 22.68. The 
distribution of deaths among the months and seasons has been less unequal 
than usual. The proportion of children under five years, too, has been smaller. 
These facts are justly attributed to the absence of extremes of cold and heat 
during this year. Especially are they due to an unusually temperate summer. 
Thus, cholera infantum exhibits a mortality only about two-thirds that of 1873, 
and one-half that of 1872. Zymotic diseases generally were less fatal than 
usual. Scarlatina, though slightly in excess of 1873, is yet beneath its average. 
as a cause of death. The mortality from diphtheria, though larger than for five 
years past, is yet very much less than the previous average. 

The proportion of marriages to one thousand persons living, fell off from 
10.52, in 1873, to 8.56. This is attributed to financial troubles. 

The exhaustive and multiform tables present many curious and suggestive 
facts. We must forbear reference to these at this time ; especially as many of 
them were noted in our review of the report for 1873. 

The coloured charts exhibiting the rise and fall of mortality, marriages, etc. 
under various conditions, are beautifully executed, and apparently more nu- 
merous than ever before. For the ingenuity and skill with which he has 
devised these graphic pictures of the relations between different phenomena. 



254 Bibliographical Notices. [Jan. 

the secretary. Dr. "\V. H. Ford, deserves great credit. Indeed, the entire work 
is one of which he may well feel proud. 

2. This work, like its predecessor noticed in the Journal for July, 1874, is an 
excellent specimen of its kind. The general report is full of sound sense and 
practical wisdom. There is an earnestness and vigour about it that indicates 
thorough belief in sanitary medicine, and a determination to make it fruitful. 

Besides the general report, the Secretary, Dr. Hexrt B. Baker, contributes 
an elaborate paper upon " Cerebro-spinal Meningitis." This is founded upon 
an epidemic which occurred recently in two counties. The cases reported are 
89. with 29 deaths. Especial attention is directed to the study of possible 
causes of the disease. The power of ergot and other fungi to produce symp- 
toms closely resembling those of cerebro-spinal meningitis, is illustrated at 
considerable length. 

Dr. H. 0. Hitchcock, the President, makes a most vigorous attack upon 
alcohol, in his annual address. The views held would generally be considered 
extreme. Indeed, while it certainly is almost impossible to overstate the evils 
of intemperance, direct and remote, there are yet some statements here made 
which are exaggerated, and some recommendations which are impracticable. 
One good idea, however, is to oblige all makers of '' bitters" to state upon 
their labels the percentage of alcohol contained. 

Prof. R. C. Kedzie, who contributed so many and so excellent papers to the 
first report, again appears as the author of extremely important investigations 
and suggestions. 

" Table syrups" were found by him very frequently adulterated. Not only is 
their sweetness due often to grape-sugar made from starch, but also they con- 
tain lime, copperas, and free sulphuric acid in large amounts. 

Treating for the second time of " poisonous wall-papers," the Prof, prints 
several letters from persons who were led by his first paper to the discovery of 
the true cause of some cases of mysterious illness. One hundred scrap-books 
containing a brief essay on the subject, with description of symptoms, and actual 
cases, and leaves formed of specimens of arsenical papers, have been prepared 
by the Board for the good of the public. A copy has been placed in every public 
library of the State. 'JMie work is entitled " Shadows from the "Walls of Death," 
with a strikingly appropriate motto from Leviticus, chap. xiv. 

Writing upon the " Resuscitation of the Drowned," Dr. Kedzie states 
an indisputable and lamentable fact when he says that very many persons taken 
from the water are allowed to die without an effort at restoration, whose lives 
might have been saved. Practical rules, compiled from those of the " Life 
Saving Society" of New York, and from those proposed by Dr. Beech, have 
been distributed, in pocket form, and on large cards, throughout the State. 

B. L. R. 



1876.] 255 



QUARTERLY SUMMAEY 

OF THE 

IMPROVEMENTS AND DISCOVERIES 

IN TIIK 

MEDICAL SCIENCES. 



ANATOMY AND PHYSIOLOGY. 

1. On the Vaso-dilator Ac/ion of the Glosso-pharyngcal Nerve on. the 
Vessels of the Mucous Alcvihraiw at the Base of the Tongue. — A. Vulpian 
{Comptes Ke)ulHs, Ix.xx. 330) shows that the fjlosso-phiiryngoal is the vaso- 
dihitor nerve for the posterior parts of the lingual mucous membrane, just as 
the chorda tympani is for the anterior part of the tongue. Electrical stimula- 
tion of the glosso-pharyngeal produces intense redness of the part of the 
tongue supplied by that nerve. Further, the author has convinced himself 
that, after destruction of all anastomoses, this action of the glosso-pharyngeal 
nerve remains the same.— Loud. Med. Fecord, Nov. 15, 1875. 

2. Jtesearches ov the Ovary of the Foetxts and Neio-horn Child — Two sets of 
investigations on this subject have just been published, one by Dr. Haussmann 
in the Centralblatt (No. 8'J). and one by Dr. Sinety in Brown-Sequard's Archives 
de Physiolagie (No. 5). It has long been known, in fact it was observed by 
Malpighi and Valisneri, that the Graafian follicles are occasionally found fully 
developed in the foetus at about the full ])eriod, and Grohe and iSlawjansky, as 
well as Haussmann, have satisfactorily shown that the constricting ofi' of the 
primordial follicles and the growth of the Graafian follicles, though not their 
rupture, is quite independent of the menstrual period. Haussmann's observa- 
tions, which were made upon eighty-four subjects, show that such premature 
development of the follicles takes place in about 10 per cent, of all cases, and 
he alludes to it as a possible and hitherto unsuspected cause of amenorrhcea 
and sterility. Dr. Sin^ty goes so far as to maintain that at about the period of 
birth a sudden development {poust<6e) of the internal organs of generation 
always takes place in connection with the development of the mammte that 
occurs at the same period. The hypertrophy of the Graafian follicles observed 
at this age must not, however, he thinks, be regarded as the point of departure 
of ovarian tumours, but of a normal, more or less active, physiological pro- 
cess. 

3. Action of Alkcdies upon the Composition of the Blood. — Pupier has ex- 
perimentally investigated this subject, and he cites the following case : M. Z., 
aged 47, had taken during twenty-nine years a daily dose of from 240 to 300 
grains of anhydrous bicarbonate of soda, without any anajraia or loss of health. 
The blood appeared to be as rich in coloured corpuscles as usual, and M. Z. 
was rather plethoric than otherwise. The conclusions Pupier arrives at, after 
experimental inquiry, are (1), that the administration of alkalies, in a state of 



256 Progress of the Medical Sciences. [Jan. 

health, tends to augment the number of red corpuscles, to Increase the tem- 
perature and weight of the subject, and to favour trophic phenomena ; (2) that 
in a diseased condition of the tissues of considerable extent, they produce 
anaemia by aiding in morbid changes ; and, (3) " on the one hand, they increase 
physiological function, while, on the other, they stimulate pathological pro- 
cesses." The memoir was presented by M. CI. Bernard. — Edinhurgh Med. 
Journ., Oct. 1875, from Comples Rendus, May, 1875. 



MATERIA MEDICA, GENERAL THERAPEUTICS, 
AND PHARMACY. 

4. Warburg' s Tincture. — This anti-pyretic remedy, which has attained much 
celebrity, and the composition of which was kept secret, has just been made 
public, in a paper by Prof. Maclean, of the Netley Medical School, published 
in the Medical Times and Gazette, of Nov. 13, 1875. 

" It will be seen," says Prof. Maclean, "that quinine is the most important 
ingredient in the formula, each ounce bottle containing nine grains and a half 
of the alkaloid. Its presence has been detected by every chemist who has at- 
tempted its analysis, and never doubted by any medical man of experience who 
has used the tincture. Many will say ' after all, this vaunted remedy is only qui- 
nine concealed in a farrago of inert substances for purposes of mystification.' 
To this objection my answer is : I have treated remittent fevers of every degree 
of severity, contracted in the jungles of the Deccan and Mysore, at the base of 
mountain ranges in India, on the Coromandel coast, in the pestilential high- 
lands of the Northern Division of the Madras Presidency, on the malarial 
rivers of China, and in men brought to Netley Hospital from the swamps of the 
Gold Coast, and I affirm that I have never seen quinine, when given alone, act 
in the manner characteristic of this tincture. And, although I yield to no one 
in my high opinion of the inestimable value of quiuine, 1 have never seen a 
single dose of it given alone, to the extent of nine grains and a half, suffice 
to arrest an exacerbation of remittent fever, much less prevent its recurrence ; 
while nothing is more common than to see the same quantity of the alkaloid in 
Warburg's tincture bring about both results." 

The following is the formula for its preparation : — 

R. Aloes (Socotr.) libram ; rad. rhei (East India); sem. angelicse ; 'confect. 
feet, damocratis; ana uncias quatuor. 

Rad. helenii (s. enulte) ; croci salivi; sem. fcenicul. ; ^cret. prjeparat. ; ana 
uncias duas. 

Rad. gentianjE ; rad. zedoariae; pip. cubeb. ; myrrh, elect.; camphor; ^bolet. 
laricis ; ana unciam. 

The above ingredients are to be digested with 500 oz. proof spirits in a water- 
bath for twelve hours ; then expressed, and added ten ounces of disulphate of 
quinine ; the mixture to be replaced into the water-bath till all quinine be dis- 
solved. The liquor, when cool, is to be filtered, and is then fit for use. 

The mode of administering it is as follows : — 

" One half ounce (half a bottle) is given alone, without dilution, after the 
bowels have been evacuated by any convenient purgative, all drink being 
withheld. In three hours the other half of the bottle is administered in the 
same way. Soon afterwards, particularly in hot climates, profuse, but seldom 



' This confection, which consists of au immeuse variety of aromatic substances, 
was once officinal, and is to be found in the Loudon Pharuiacojaia, 174G. 

2 Dr. Warbnrg infoirus uie that this ingiedient was added to correct the other- 
wise extremely acrid taste of the Tincture. Many other substances were tried, 
but none answered so well as prepared chalk. 

* This is the Polyporus Laricis (P. officinalis, Boletus purgans or Larch Agaric), 
" formerly," says Pereira, "used as a drattic purgative, and still kept by the 
herbalist." 



1870.] Materia Medica, General Therapeutics, etc. 257 

oxhaustin?. perspiration is prodiKcil. This has a strong aromatic odour, which 
I have often detected about the patient and his room on the following day. 
Witii tliis there is a rapid decline of temperature, immediate abatement of 
frontal lieadache — in a word, complete defervescence — and it seldom happens 
that a second bottle is required ; if so, the dose must be repeated as above. In 
very adynamic cases, if the sweating threatens to prove exhausting, nourish- 
ment in the shape of beef-tea, with the addition of Liebig's extract, and some 
wine or brandy of good quality, may be required." 

5. Monohromklc of Camphor. — In a recently published pamphlet Dr. 
Pathaui.t furnishes an abstract of the literature of this compound, which was 
discovered and described by Swartz in 18(12, and was introduced into medicine 
in 1871 by DeneflTe. On the physiological action of the drug, to wliich he adds 
one or two original observations, he closely follows M. Bourneville and Dr. 
Lawson, and finds that it is eliminated in the urine. 

It lessens the frequency of the pulse and the number of respirations, causes 
a marked and regular depression of temperature, and exerts a decided hypnotic 
influence (on guinea-pigs and rabbits). On the whole, it appears to be an 
energetic nervous sedative and an undoubted anti-spasmodic; but certain 
difSculties and objections attend its continued use. 

It has been administered in delirium tremens, insomnia, chorea, infantile 
convulsions, hysteria, dyspnoea, neuralgia, irritative genito-urinary affections, 
and in a considerable number of cases of epilepsy by M. Bourneville. This 
observer thinks that the bromide of camphor is formally indicated in vertiginous 
epilepsy ; but, with the exception of reducing their frequency, it cannot be said 
to have much influence on the fits themselves. 

From the insolubility of the drug in water, it may be administered in pills, 
drag4es, or capsules; preferably the latter (each capsule containing 3 grs.). 
The doses hitherto given have varied from G to 60 grs. The remedy is not 
adapted for hypodermic injection. 

The experience of MM. Trasbot, Dujardin-Beaumetz, and Gubler [London 
Med. Record, March 3, 1875) does not confirm the good effects claimed for 
this medicine, and doubt is cast upon some of ]M. Bourneville's physiological 
ob.servations. 

Dr. Yalenti y Yivo {Siglo Medico, April 18, 1875) has made a series of re- 
searches on dogs, and has arrived at the conclusion that monobromide of 
camphor may be considered antidotal to strychnia. The physiological antago- 
nism is comparatively limited, and a full dose, from 60 to 90 grs., should be 
given in small and repeated quantities. — Dublin Med. Journal, ricpt. 1875. 

6. Salicylate of Soda. — The Berliner Klin. Wochenschrifl contains an 
article on the effects of salicylate of soda as an antifebrile, by Dr. Moeli, of 
the Rostock University Hospital. According to Kiilbe, the salts of salicylic 
acid possess no antiseptic properties, which has been confirmed by other obser- 
vers, their preserving effects on organic matter being derived from the amount 
of free acid in them and proportionate to it. The trials of this at present in 
Germany rather fashionable acid as an antifebrile induced the author to try 
the salt as such, the presence of alkali being indispensable for the absorption 
of the acid into the circulation, and soda appearing preferable to potassa. The 
solution of salicylate of soda (the acid is obtained from this salt by the whole- 
sale manufacturing process, and therefore the latter is not dearer than the 
former) is of a brown colour and unpleasant taste; the addition of extract of 
glycyrrhiza or some wine taken with the dose is therefore recommended. From 
tour to five grammes of the salt is the usual quantity given every other evening 
in cases where the larger doses of the sulphate of quinine (1.5 to 2.0 grammes) 
would be required. Several cases of typhoid fever (altogether seven), in which 
the drug was used without the cold bath or any other remedy, showed after 
each dose a constant decrease of temperature (from 2° to 3° C), lasting over 
twenty-four hours, combined with a diminished frequency of pulse. An increase 
in the quantity of urine was not observed in the twenty-four cases of miscel- 
laneous febrile diseases in which the salt had been administered. In half the 

No. CXLL— Jan. 1876. 17 



258 Progress op the Medical Sciences. [Jan. 

number a profuse perspiration accompaniefl the fall of temperature, as has 
been recorded by Buss, after the use of salicylic acid. In some cases, how- 
ever, the salt effected a decrease of body-heat from 40.4° to 37.0° C. without 
any sweating at all. In four cases sickness and vomiting compelled him to use 
the salt solution as an enema, after which a distinct fail of temperature fol- 
lowed, though of less importance than after an application by mouth. Sub- 
cutaneous injections must be made with a neutral solution of the salt to avoid 
severe pain which follows after injection of the acid. 'I'he author insists on 
the usefulness of salicylate of soda as an antifebrile remedy in comparison with 
the antiseptic but not antifebrile effect of benzoic acid. This chemical body in 
both forms, as derived from the urine of animals, as well as the acid made of 
the natural resin, possesses, according to the late experiments of Professors 
Salkowski and Fleck, antiseptic properties even in a higher degree than sali- 
cylic acid. The latter, however, acts undoubtedly as an effective antipyretic. 
Antiseptic treatment begins to assert its importance and success no less in 
medical cases than in surgery. — Lancet, Oct. 9, 1875. 

7. Effects of certain Cathartic Medicines on the Bilicay Secretion of the 
Dog. — The British Med. Journal has in course of publication a report by Dr. 
Rdtherford, assisted by M. Tigxal, a committee of the association on this 
subject. Dr. R. has repeated Eohrig's experiments with a somewhat altered 
and improved mode of procedure. He records the amount of bile secreted 
every fifteen minutes, and the variations which occur are represented in the 
form of a curve. He also made frequent analyses, by which an accurate idea 
of the solid constituents of the bile could be formed ; while the alimentary 
canal was carefully examined post mortem, and the amount of intestinal irri- 
tation noted 

Tested by this method, croton oil did not appear to deserve so high a place 
as a hepatic stimulant as is stated by Rohrig, and there was evidence of so 
much intestinal irritation that its use was abandoned. Podophylline increased 
greatly the amount of biliary secretion, and was found to act much more en- 
ergetically when previously mixed with bile, which acted as a solvent. The 
marked increase in the amount of bile, attributed by Rohrig to the action of 
aloes, was in all respects confirmed by three experiments. Rhubarb proved a 
much more powerful hepatic stimulant than Rohrig's experiments led him to 
suppose: repeated doses causing renewed increase in secretion, and analysis 
demonstrating that, notwithstanding the great increase in quantity, the solid 
constituents were present in the same proportion as in the normal bile. Senna 
somewhat increased the amount of secretion, and at the same time rendered 
the bile more watery. Colchicum was found to act decidedly as a cholagogue, 
the rapidity of secretion being much increased. Scammony and taraxacum 
had also a cholagogue action, but in a less marked degree. 

On the other hand, calomel failed to produce any increase in the biliary se- 
cretion, a decided diminution occurring in all but one case, and in every one 
the bile was rendered more watery. Gamboge and castor oil had not a marked 
effect, while the secretion was diminished after alcohol had been injected into 
the stomach. 

From these results, it would appear that certain medicines given in proper 
doses to fasting dogs do cause an increase in the secretion of bile; but it is 
certain that mercury is not one of these agents. 

The reporter believes that energetic purgation tends to hinder the secretion 
of bile, and thinks that the diminution which was found by Dr. Bennett's com- 
mittee to follow the administration of podophylline probably depended upon 
the fact that its severe purgative action impeded the absorption of food, and 
thus lessened the amount of bile formed. He conceives that the administra- 
tion of any remedy which acts both as a hepatic and an intestinal stimulant to 
an animal before the process of digestion is complete, has two distinct effects ; 
first, to increase the amount of bile ; and, secondly, to diminish the absorption, 
of food and bile from the small intestine. 

T'he precise mode of action of these cholagogue medicines the author does 
not pretend to have definitely settled, the chief object of the investigation 



1876. J Materia Medica, General Therapeutics, etc. 259 

bciuj? merely to ascertain the facts of the case. Some reasons are, however, 
adduced for believing that the agents are absorbed into the portal circulation 
and act on the liver directly in passing through that organ. 

The reporter disclaims any intention of reopening the old discussion as to 
the cholagogue effect of mercury on the human subject, and he distinctly points 
out that the present researches are to be regarded simply as a contribution to 
comparative physiological pharmacology. At the same time, he invites clinical 
investigators to compare the results he has obtained by experiment with those 
which may be observed in human pathology and therapeutics. It is to be hoped 
that this report may enlist into the ranks of precise clinical observers some of 
those physicians who are in the habit of giving their five grains of blue pill, 
with equal confidence in its efficacy and indifference as to its mode of action. — 
Brit. Med. Journ., Oct. 23, 1875. 

8. Tlie Physiological Properties of Aldehyd. — Acetic aldehyd, CoHjO, a 
volatile liquid, prepared by the slow oxidation of alcohol in various ways, has 
recently been examined, from a physiological point of view, by Drs. Albkrto.m 
and LussA.NA, of Padua, and the following account of their results is an alistract 
of a portion of their recentl^'-published monograph On Alcohol, Aldehyd, and 
the Vinous Ethers, (a) Aldehyd agrees in its elementary properties with those 
of alcohol; it coagulates albuminous substances, and whatever dissolves in al- 
cohol is also soluble in aldehyd. It possesses powerful antiputrescent proper- 
ties : meat can be kept for months, with scarcely any alteration, in an aqueous 
solution containing from I to 3 per cent, of aldehyd. Two hundred grammes 
of urine, to which four grammes of aldehyd had been added, remained three 
months without undergoing the slightest decomposition. Its vapours are also 
equally active. A few grammes of aldehyd poured on the bottom of a vessel 
containing such easily decomposing bodies as the brain and liver, will preserve 
them quite fresh for two months. The physiological action of aldehyd on ani- 
mals is a very powerful one. From three to five grammes diluted with water 
and injected into the veins of a moderate-sized dog almost instantaneously 
arrest the respiration, and produce a condition of coma. The heart's action is, 
however, only sliglitly weakened, but the muscles are paralyzed, and sensation 
and reflex excitability are temporarily destroyed. As a rule, however, the 
animals recover completely in a little while. In smaller doses the aldehyd pro- 
duces an intoxication similar to that of alcohol, but there is an almost com- 
plete loss of sensibility. If the drug is given by the stomach, larger doses of 
it are required to produce the same effects than if it is injected into the veins, 
and it gives rise to intense irritation in that organ, and even to gangrene of the 
mucous membrane, owing to its caustic properties. 

Owing to its great volatility, large quantities of aldehyd can be inhaled 
through the lungs. The most remarkable action of aldehyd in the organism is 
that which it exerts on the respiratory apparatus : while small quantities im- 
mediately accelerate the respiration, large ones arrest it altogether. The ani- 
mals may then continue without breathing for as much as half an hour, while 
all the time the heart's contractions remain either normal, or slightly less 
frequent in number and somewhat increased in strength. Dogs which have not 
made a single inspiration for ten or fifteen minutes may thus completely re- 
cover without any artificial aid. During the stage of asphyxia, irritation of 
the pneumogastric nerves has not the slightest influence on tlie heart, and it is 
only when the breathing commences that the nerves gradually recover their 
irritability. As long, however, as the animal is at all under the action of the 
aldehyd, all attempts to stop the heart by irritation of the vagus are unsuccess- 
ful; its pulsations are only rendered smaller and less frequent while the blood 
pressure is diminished. Aldehyd diminishes the temperature of the body in 
proportion to the dose exhibited. During the stage of asphyxia the temper- 
ature may fall even as much as 4° to 5° Cent. (7° to 9^ Fahr.). Animals forci- 
bly resist attempts to make them inhale the vapours of aldehyd ; but their 
sensibility and power of motion are completely abolished in about a minute. 
If the inhalation is continued, their pupils become widely dilated, respiration 
ceases, and they lie, to all appearance, dead — the only sign of life being the 



260 Progress of the Medical Sciences. [Jan. 

movements of the heart. In spite of all this, they quickly recover if the inha- 
lation is stopped, without vomiting or other unpleasant symptoms. Of thirty 
deeply narcotized dogs only two died. The vessels of the brain, observed 
through an opening in the skull, arc dilated at the beginning of inhalation, but 
they contract and leave the brain anaemic when the animal is narcotized, just 
as they do in animals under chloroform or ether. 

The anaesthetic effect of the aldehyd on human beings has been as yet very 
little investigated, but it is doubtful whether its properties of arresting the 
breathing, and its irritating action on the lungs and stomach, will not seriously 
interfere with any attempt to employ it in surgical operations. — 31ed. Times 
and Gaz., Sept. 18, 1875. 

9. Therapeutic Use of Broviliydrate of Quinia. — According to Prof. Gub- 
i.ER, this preparation has special properties which belong neither to bromine 
nor to quinia separately, but which seem to result from their combination. Like 
sulphate of quinia, the bromhydrate lessens calorification, diminishes com- 
bustion, contracts the capillaries, and augments vascular tension; but acts less 
on the organ of hearing. 

His conclusions are as follows : — • 

1. The bromhydrate of quinia corresponding to the sulphate of the same 
base, is more soluble and richer in the alkaloid than the latter. 

2. It possesses the physiological properties of the salts of quinia in general, 
and probably also the therapeutic properties of its officinal congener. 

3. Nevertheless the action of the bromhydrate seems to differ from that of 
the sulphate, not only by inducing less quinia into.xication, but also by pro- 
ducing a marked tendency to nervous sedation and hypnotism. 

4. These properties indicate its special use in the treatment of congestive 
and febrile affections of the nervous system ; neuralgia, neuritis, irritative 
neuroses, encephalic hyperaemia, etc., and for the relief of which excellent 
results have already been obtained. 

5. The bromhydrate of quinia has shown remarkable power in obstinate 
vomitings, it has been useful in many cases ordinarily amenable to the sulphate 
of quinia, visceral or articular fluxions of diathetic, rheumatic, or gouty origin, 
symptomatic fevers, from cold, etc. 

6. This new medicine has been given in doses of 40 centigrammes to 1 
gramme a day in portions of 20 centigrammes, sometimes in pilular form, some- 
times in hypodermic injections. 

7. Injected into the cellular tissue, the bromhydrate of quinia is entirely un- 
irritating. In no case, has a hypodermic injection of 20 centigrammes of it, 
equivalent to 30 centigrammes of the sulphate, been followed by the slightest 
inflammation, and on the following day there was no redness or tumefaction at 
the seat of puncture. 

8. This perfect innocuousness, with its greater solubility, is an undoubted 
advantage of this new salt of quinia, and renders it especially preferable when- 
ever it is desirable to administer quinia hypodermically. — Gaz. Hebdom., Sept. 
17, from Journal de Thdrapeutique, July 10 and Sept. 10, 1875. 

10. Hypodermic Injection of Nutritious Substances. — Dr. Kreug gives an 
account of a trial of this which he has recently made. Drs. Menzel and Perco, 
he observes, were the iirst persons who tried, in 18G9, some experiments on 
dogs on the absorption of articles of nutriment by the subcutaneous tissue, 
and found that an ounce of fluid fat was by the cud of forty-eight hours com- 
pletely absorbed without inducing any peculiar symptoms of reaction. The 
same was observed with regard to a solution of sugar, milk, and even the yelk 
of egg. Only one experiment seems to have been tried on man, and that only 
with nine grains. These authors state also that Strieker and Oser had made 
experiments with the peptons. 

Dr. Kreug observes that cases are alw.ays being met with in which artificial 
feeding is necessary, but cannot be executed by the ordinary means ; and it may 
be required on various occasions to sustain life, at all events temporarily, until 
other means, for the time inapplicable, can again be resorted to. There are 



18TG.] Materia Medica, General Therapeutics, etc. 2G1 

no data for statinj,' liow long the functions of the stomach may be superseded 
hy subcutaneous injections ; but, at all events, this is possible for several weeks, 
during which time other measures may be resorted to. In illustration of this 
the following case is related : — 

C. E., aged fifty-seven, a Hungarian proprietor, has been in an asylum at 
Ober-Dobling since 18G8, and for the purpose of suicide had often refused all 
food, so that for twenty-seven months at a time he had to be daily fed by means 
of the tube ; of late he has been more inconstant in his refusals, sometimes 
eating even abundantly, and at others allowing himself to be fed. On January 
18, however, he began again to absolutely refuse food, and so continued, with 
the exception of one day, to the 24th, when it was resolved to feed him by the 
tube as heretofore; but all attempts to pass this proved fruitless, such violent 
coughing and irritation did it cause, so that the patient became breathless and 
cyanotic. Even when the tube was got into the stomach, the fluid injected was 
immediately expelled again by its side; so that the whole procedure, inducing 
so much suffering, proved useless. As ten days had elapsed without his taking 
any food, with the e.\ception of some soup once, it was resolved to try the sub- 
cutaneous injection, under the hope that a slight quantity of nutriment might 
be so supplied, so as to ward off danger to life, and perhaps exert a favourable 
impression on the patient when he found his resistance unavailing. Olive oil 
was the substance injected, the syringe employed holding fifteen cubic centi- 
metres. To the syringe was attached a thin caoutchouc tube, terminated by 
the canula of an ordinary subcutaneous syringe ; so that the movements of the 
patient did not derange the working of the apparatus. One or two syringes 
full were injected daily ; therefore from fifteen to thirty cubic centimetres of 
oil. At first each syringe-full was thrown into five apertures, but afterwards 
into thi'ee, or even only two. The oil passed drop by drop out of the canula, 
so that at first an hour, and afterwards half an hour, was occupied in the emp- 
tying of each syringe. This slow procedure rendered the injection painless, 
and prevented reaction, which, as well as pain, was caused when the injection 
was made too rapidly, or too much fluid thrown into one spot. Most of the 
injections were made in the foot, some in the belly, and others in the sides. 
Some effect was produced upon the patient's moral condition, so that he par- 
tially abandoned his opposition to food. Thus, during thirty-nine days, he com- 
pletely fasted during nine, ate voluntarily during ten, and was supported by the 
injections during the other twenty. It was not possible to weigh him, but his 
general appearance was not changed for the worse. With some occasional ex- 
ceptions, when the injections were resumed, the patient gradually abandoned 
his resistance, and at last ate in a natural way, the experiment lasting alto- 
gether about two months. The chloroform odour characteristic of fasting 
persons disappeared soon after the first injection. — Mtd. Times and Gaz., Sept. 
25, from Wiener Med. }Yochciischr'/(, Aug. 31, 1875. 

11. The Question of Transfusion. — Prof. P. L. Panu.m, of Copenhagen, has 
felt called upon to review the question of transfusion, because his former con- 
clusions have been controverted. He published two articles on the subject in 
vols, xxvii. and xxix. of Virchow's Ardiiv, the effect of which .«eemed to be that 
the use of human detibrinated blood superseded the blood of other animals, espe- 
cially thatof the calf, lamb, etc., which had been recommended by Brown-Se- 
quard. In 1873, however, Gesellius and Hasse have reasserted the advantages 
to be gained by the direct transfusion of the blood of certain animals. In the 
present article the author considers, first, the indications for the use of transfu- 
sion ; and secondly, the method and kind of blood to be employed. 

It has been proved by experiment that an animal cannot live without the 
supply of fresh nourishment by the alimentary canal. Blood transfused into 
the vessels does not take the place of food, and does not prevent an animal 
which is being starved from dying of inanition. The extra supply of blood 
corpuscles does not serve as nutriment, but seems rather to be deleterious, 
increasing the waste, apparently by using up an additional quantity of oxygen. 
Blood is to be regarded as a tissue which is used as the vehicle by which nour- 
ishment is carried to the other tissues, perhaps altering the constituents slightly 



262 Progress of the Medical Sciences. [Jan. 

in transit, but is not itself a source of nourishment. Neither is the fibrine used 
for purposes of nutrition. Even if it were, its quantity is so small that it 
■would not be worth while transfusing blood in order that its fibrine might be 
so used. In a pound of normal blood, there is only about a gramme (15.4 
grains) of fibrine. Fibrine is further of no essential service in carrying on the 
respiratory functions. Uefibrinated venous blood is as capable of absorbing 
oxygen as that containing fibrine. In transfusing blood, therefore, we cannot 
expect to supply nourishment to the patient, we can only fill up any defect in 
the number of the blood corpuscles. The one indication for the use of trans- 
fusion is, therefore, deficiency of blood corpuscles, and the deficiency can be 
as well supplied by defibrinated as by fibrinous blood. The blood corpuscles 
may be counted by the process described by Melassez. On the other hand, we 
cannot expect, by depletion and transfusion, to remove a deleterious substance 
which is being continuously produced in the organism, as in pysemia, erysipelas, 
diphtheria. Again, in cholera the red corpuscles are relatively numerous, so 
it is of no use there. It is also useless in tetanus, melancholia, etc. The 
operation is further contraindicated where there is great weakness of the ner- 
vous system, and especially of the nerves of the heart, as there is some risk of 
pai-alysis of the heart during the operation. 

Now, as to the method to be employed, it will be gathered from the above 
remarks that the author recommends the transfusion of defibrinated blood. Of 
late, immediate transfusion from the vessels of one animal to the other has been 
recommended. But this has three great disadvantages. In order to estimate 
the quantity introduced, it would be necessary to weigh the individual before 
and after the operation, and you would be in ignorance of the quantity during 
the operation, for it would be out of the question to interrupt the operation 
in order to weigh the patient. Then by this method you may introduce 
clots, and that may lead to serious results. And lastly, you cannot readily 
check the speed of the stream of blood, and too great speed may be dangerous 
to life. There is, however, no necessity to resort to this method. It has been 
proved, by experiment, that a dog which has been apparently bled to death may 
be resuscitated by the transfusion of defibrinated as well as by entire blood. 
The view of Magendie is therefore incorrect, that the presence of fibrine is of 
great importance for the passage of blood through the capillaries. Experi- 
ment shows that when defibrinated blood is transfused into the vessels of an 
animal of the same species, the corpuscles are actually transplanted, and survive 
in their new habitation. By using defibrinated blood you avoid the risk of 
embolism, which is considerable when entire blood is used. If transfusion is 
done with human blood, it should always be defibrinated, and human blood 
should not be difficult to get, as not one person in a thousand suffers in the least 
from the loss of eight or ten ounces of blood. But if the blood of an animal 
will do equally well, then, perhaps, it should be preferred. The author, how- 
ever, asserts, in contradiction to Gesellius and Hasse, that if the blood of a 
difierent species be used it acts like a poison. Experiment proves that if the 
blood of the lamb or calf be transfused into the vessels of a man or dog, the 
urine becomes bloody or black in colour, there are often considerable hemor- 
rhages, the patient complains of dulness, weariness, pain, and sleepiness. When 
death occurs, there is found to be bloody fluid in the serous cavities and tissues. 
The urine, although it appears bloody, does not contain blood corpuscles. 
There is sometimes suppression of urine. It will be seen, therefore, that the 
author is still strongly in favour of his former view, that defibrinated human 
blood should always be used when transfusion is required. — Glasgoio Medical 
Journal, Oct. 1875, from Virchoiv's Archiv. 



187G.] Medical Pathology and Therapeutics. 2(\^ 



MEDK'AL PATHOLOGY AND TTTERAPEUTICS, AND PRACTICAL 

MEDICINE. 

12. Ijnlccrmin a Primary Blood Disease — Prof. Btesiadecki, oF Cracow, 
has lately atlvocated a new llioory as to the nature of hika^nia. founrled on the 
results iif the careful anatomical and microscopical examination of certain 
cases which have come before him, as well as on other considerations. He 
believes leukaemia to be a primary disease of the solid elements of the blood 
{ei)ie Pari'iirhyinerkra7)lni>g des Blx/es), in which the white corpuscles are 
produeod normally, but are afterwards prevented from developinj^ into red cor- 
puscles liy retronfrade changes which they underiro, so that the number of the 
latter cells appears to be diminished. 

Biesiadecki regards the anatomical alterations in the spleen, lymphatic 
plands. liver, kidneys, etc., as due secondarily to the altered proportions of the 
elements of the blood. His reasons foi this opinion are as follows {Centralhhdt, 
No. 44. s. 7.57): L Neither the spleen nor the lymphatic jjlands, although so 
much increased in size, exhibit such changes as should lead one to conclude 
that there must be a greater production of white blood corpuscles in conse- 
quence. 2. In leukajmia, not only the parenchyma of the spleen, but also of 
the enlarged liver, and of the kidneys, is not only not hypertrophied, but, on 
the contrary, is in a state of atrophy. 3. The colourless blood corpuscles are 
not only relatively more numerous in leukicmia, but they are also of greater 
size, owing to a kind of colloid degeneration of their protoplasm. 4. These 
degenerated cells are deposited in the same organs and parts of organs as those 
in which blood cells containing pigment or vermilion collect. .5. In Biesia- 
decki's special case, a striking alteration was observed in the blood, before any 
swelling of the lymphatic glands or any sign of the tumours which afterwards 
appeared in the skin had been noticed. 6. After extirpation of the spleen in 
animals, neither the blood nor any organ exhibits important alterations. 

While speaking of leuka;mia, we may mention that Dr. Ordenstein, of Paris 
{Ceidralhlatt, No. 42, s. 709), suggests the possibility of a connection between 
that disease and hereditary syphilis. He discovered that the father of a patient 
of his with splenic leukaemia had had constitutional syphilis, and this fact led 
him to try anti-syphilitic remedies on the son. Van Swieten's liquid— a solu- 
tion of bichloride of mercury — was given for several months with surprising 
benefit, all other previous treatment having signally failed. The author pro- 
mises to publish the case ?n extenso. — 3hd. Times and Gaz , Nov. 13, 187.5. 

13. Pathological Anatomy of Endemic Malarial Fevers. — In the Archives 
de Physiologie, No. 5, 1875, Prof. KEr.soii, of the military hospital Val-de- 
Grace, gives an account of a study of the changes found in the blood of 
patients suffering from malarial fever, made hy means of this very valuable 
method. 

The conclusions arrived at are, that in this fever there is — (1) A diminution 
in the number of the cellular elements of the blood ; (2) An augmentation in 
the size of the red globules; (3) A development of a black pigment which 
does not enter into the normal composition of the fluid. The observations 
extend over three classes of cases — simple fevers, pernicious (malignant) 
fevers, and cases of cachexia. 

As an instance of the method of observation, the following case is translated 
entire : — 

Ob.s. 1. — F., aet. 23, was 21 months in Africa. Had fever for the first time 
in the middle of August, 1874. Had three attacks of quotidian ague. On 
the 24th August, was admitted into the hospital for an organic affection of the 
heart. The fever relapsed in the hospital on 2d September ; paroxysm severe 
between 11 A. M. and 3 P. M. 3d September, morning, free from fever; red 
globules, 4,273,240 in a millimetre cube. 10 A. M., rigors followed by hot 
stage. 3 P. M., pulse 120 ; temperature 40.2° (Centig.) ; red globules 3,441,160. 
4th September, morning, pulse 96 ; temperature 37°; red globules 3,209,724; 



264 Progress of the Medical Sciences. [Jan. 

sulphate of quinine in frequent doses. There are no more paroxysms. Dis- 
charged the "i.ilh. Tn twenty-four hours this patient lost more than a million 
of globules per millimetre cube. 

In cases of proloni^ed fever, and in cachectic case.s, the loss was much 
"•renter. Professor Kelsch states, en rdfium^, that when the variations in the 
number of globules in a vigorous man are followed from the first paroxysm to 
the stage of profound anaemia, it is found — (1) That the ansemia comes on 
very rapidly. In less than a month the globules fall from five millions to a 
million and a half or less per millimetre cube ; (2) That there are three stages 
in the numerical variations of the red globules, which correspond with tolerable 
accuracy to the changes in the fever, as observed clinically. A first and short 
one, in which the globular deficit, exceedingly rapid, is reckoned by several 
hundred thousands daily, it corresponds to the initial stage of the fever, 
when there are acute febrile symptoms of more or less gravity, which are con- 
tinued or remittent. 

A second, which lasts longer than the first, during which the deficit for each 
paroxysm becomes less. The fever is still severe, but the intermitting type 
(quotidian or tertian) has taken the place of the remittent. During these two 
first stages the globules have continued to decrease in number. 

Finally, a third, in which the number of globules ceases to fall. It oscillates 
at first for some time around a minimum. The blood still loses under the in- 
fluence of the paroxysm, but the losses are less marked than in the two first 
periods, and are compensated by the salutary influence of periods free from 
fever, during which the globules are regenerated. This regeneration seldom 
takes place during the two preceding stages. Clinically, this last phase is 
marked by isolated attacks, between which there are longer or shorter periods, 
during which there is no fever. 

Professor Kelsch further gives a number of measurements which show that 
the red globules increase in size, and that in malignant cases white corpuscles 
are observed, containing masses of pigment. — Edinburgh Mtd. Journ., Dec. 
1875. 

14. The Treatment of Rdudal Fevers by Aisenic. — This paper, by M. Sistach 
{Archiven G^n^rales de M^decine, September, 1875), comprises the fruits of a 
large experience gathered at the military hospital of Bona, in Algeria, one of 
the most malarious stations in that malarious colony. The author arranges his 
cases under four heads: intermittent faver, remittent fever, pernicious paludal 
fever, and paludal cachexia. 'I'he first group includes 229 cases, of which 136 
were quotidian, seventy-four tertian, eleven quartan, five irregular, and three 
masked. Algerian intermittents are most frequent and severe during the sum- 
mer months. The number of paroxysms is always greater in the first attack 
than in subsequent ones ; and this difference is observed, whatever be the mode 
of treatment employed. Indeed, M. Laveran noticed it in his account of eighty- 
eight cases treated on the expectant method of Blidah. In comparing the 
results of treatment with those of simple expectation, it is indispensable that 
the cases should all have been subject to the same telluric and climatic condi- 
tions. In a comparatively healthy locality, such as Blidah, recovery without 
specific treatment is not uncommon ; whereas at Bona, where the patient con- 
tinues to be exposed to miasmatic influences of a most intense kind, attempts 
at expectation may prove dangerous, if not fatal. Each of the 130 cases of 
quotidian ague furnished an average number of 1.7 paroxysms after the treat- 
ment by arsenious acid had been begun ; this average only amounting to 0.75 
in the seventy-four cases of tertian fever. Fremy, Fuster. and Girbal had pre- 
viously noticed that the febrifuge action of arsenic manifested itself more 
promptly in the latter than in the former variety of the disease. 

The following are the rules laid down by the author for the administration of 
the remedy. They are essentially the same as those originally promulgated by 
Boudin; and the failures which have been recorded since his time by various 
observers must be attributed to their neglect of those details on which the 
certainty and the safety of arsenical medication depend. 1. The arsenious acid 
must be given in solution. 'I'he previous administration of an emetic is only 



1876.] Medical Pathology and Therapeutics. 2C5 

necessary when the stoinatli is overloaded. 2. The remedy must he freely 
diluted, and fiiveii in vrry small doses, frcfineutly rejjeated. 3. The quantity 
taken in twenty-lour hours must be proportionate to the severity of the fever, 
to the length of time it has lasted, and to the nature of the locality as 
regards malaria. 4. We must bettin by givinfr from three to five centigrammes 
daily (.45 to .7.") grain), to be continued as long as the paro.xysms recur. .5. 
After the paro.xysms have ceased to recur, the dose ought to be diminished by 
one centigramme every day; but the j)atieut must continue to tal<e about one 
lentigramme daily for some ten days after he is apparently free from symptoms. 
Wlicn these directions are carefully attended to, the use of arsenious acid is 
wholly free from risk. A few cases of conjunctival irritation, sometimes asso- 
ciated with redema of the eyelids and cheeks, occasional colicky pains with 
slight diarrhcea, and in very rare instances nausea and vomiting ; such are the 
only accidents which M. Sistach has ever observed. He concludes that for the 
treatment of intermittent fever arsenious acid is as effeclual as rpiinine, and 
more effectual tlian cinchonine or quinium ; though as regards quickness of ope- 
ration, quinine must continue to hold the foremost place. The extreme cheap- 
ness of the mineral remedy is, of course, its chief recommendation ; by substi- 
tutinif it, even partially, for quinine, many hundred thousand francs may be 
yearly saved on the war budget alone. 

Under the second head, that of remittent fever, the author's results are by no 
means favourable. The remittent form of the disease is notoriously more ob- 
stinate than the intermittent variety, and demands much larger doses of what- 
ever febrifuge remedy we may choose to employ. Now arsenious acid, if given 
in the necessary quantities, invariably aggravates thegastro-intestinal symptoms 
to a dangerous e.xtcut. Moreover, the comparative slowness of its operation 
renders it unsuitable for the treatment of a disease which does not bear delay. 
It is equally unsuitable, and for the same reasons, as a substitute for quinine in 
tlie treatment of the pernicious variety of paludal fever ; of three cases treated 
by M. Sistach with arsenious acid, two died. As regards the divers forms of 
paludal cachexia, the author asserts that neither quinine, nor arsenic, nor any 
other drug, is of any avail ; the patient's only hope of recovery lying in removal 
to a more healthy region, together with the diligent employment of hydro-the- 
rapeutic measures. — London Med. Record, Nov. l.o, 1875. 

15. Smallpox of Sheep. — It would seem from the researches of Dr. Klein 
that we are now in possession of substantial evidence that variola, if not 
caused, is at least accompanied, in the sheep, by the growth and development 
of a peculiar fungus which makes its appearance in the tissue of the corium 
and its lymphatics, and is gradually carried or penetrates into the vesicles 
formed in the rete Malpighii. This fungus, Dr. Klein proposes, since he has 
been unable to identify it with any described species, to call the " oidium variolse ;" 
and adds that it is a very important question, and one deserving alike the 
attention of physicians and anatomists, whether any form of vegetation corres- 
ponding to it is to be met with in the cowpox or in human smallpox. — Lancet, 
Nov. 27, 1875, from Philosophical Transactions. 

16. Pathology of SanslroJce. — Dr. Rudolph Arndt gives the history of three 
cases of sunstroke occurring in the persons of three healthy young soldiers 
after a long and fatiguing march, and follows the account by a review of the 
pathological changes met with after death. 

There are two features standing in strong contrast — the blanching of all the 
organs, and therewith, the over-distended condition of all their vessels above 
a certain size with dark-coloured, uncoagulated blood. 'I'he skin and muscular 
tissue were bloodless, but their large vessels full to bursting, exuding large 
drops of blood when wounded. The brain was in tlie same ansemic state 
together with its membranes, w'hilst the large veins and the sinuses were dis- 
tended with dark, nnclotted blood. The same condition obtained in the heart, 
pericardium, liver, and kidneys, as well as in the mucous membrane of the in- 
testines and bladder. In consequence of their extreme distension, the blood- 
vessels were much increased in size, and in some places, as beneath the endo- 



26() Progress of the Medical Sciences. [Jan. 

cardiurn, the pericardium, and both pleurai, the overstretching had led to 
ecchymoses. 

The singular bloodless condition of the brain-substance is an appearance 
contradictory to the generally received opinion that sunstroke is hyperemia of 
the bi'ain. This notion must have arisen from imperfect observation, noting 
the extreme engorgement of the larger vessels, especially of the veins, and 
confounding the escape of blood from such vessels, and the straining of the 
tissue thereby, with exudation from the capillary and smallest vessels of the 
viscus. But the fact is, the capillaries and minute vessels are well-nigh empty, 
and in cases more fully developed completely so, and their walls collapsed. 

'I'he cause of the parenchymatous anaemia is apparent. In all three cases 
the brain was swollen. It distended the sac of the dura mater; the gyri of 
the hemispheres were widened, flattened, and pressed together, obliterating 
the interspaces. In two of the three cases in which the abdominal viscera 
were examined, the liver and kidney exhibited the same enlargement, from 
simple swelling of their mass. The liver had aquired a more rounded form 
than normal, and its borders were thicker. Its transverse diameter seemed 
most enlarged. It had a doughy feeling, and was readily impressed by the 
fingers, the marks remaining. Its acini were distinct. 'I'he enlarged kidneys 
allowed of the ready separation of the capsule. The pale cortical substance 
looked swollen and widened, whereas the medullary substance was injected 
with blood, the congestion being greater as the pelvis was approached, this 
last part exhibiting great injection of its vessels with ecchymoses. 

The swollen brain was likewise unusually wet ; in two cases there was an 
excess of serum in the ventricles, and in the third, if not actual excess, a con- 
siderable proportion. On slicing it a watery fluid escaped, showing its highly 
oedematous condition. Its membranes, which were in places raised in a blad- 
der-like fashion, were readily separable from the subjacent tissue. 

A similar, if not identical, state of oedema existed in the kidneys and liver. 
In the latter, indeed, a dryness was remarked, but the distinctness of its acini 
indicated the presence of some interpenetrating matter, which might well seem 
to be nothing else than the serum of the blood. The greater moisture of ordi- 
nary liver-tissue is explicable from the fact of the presence of blood throughout 
it, whereas in the liver of those dead from sunstroke the hepatic tissue itself 
is bloodless. 

In the several organs the capillaries and smallest bloodvessels were com- 
pressed, and the blood forced out of them into the neighbouring veins. 

The heart was contracted in all the cases ; in one the left side was more so 
than the right. It felt hard, and its naturally bright colour was replaced by 
a dusky-red or grayish-brown. The tissue was dry and fragile, and thin sections 
of it had a lustrous aspect. The same phenomena were present in the muscles 
generally. 

The dry condition of the heart-substance and of the muscular tissue at large 
is one contrasting with the cedematous state of the brain-matter ; and Arndt, 
after remarking this fact, and taking with it the dry, though swollen, state of 
the parenchyma of the liver, and, though in a less degree, the like condition of 
the cortical substance of the kidney, is inclined to attribute that state to some- 
thing else than simple oedema, and supposes an overgrowth in size of the con- 
stituent elements of the tissues, and an excessive formation of protoplasm over- 
rich in granules. After further discussion he comes to the conclusion that 
the essential method of the process — as best illustrated in the heart-tissue and 
muscles — is inflammatory. Although wanting in the usually recorded charac- 
ters of encephalitis, he nevertheless considers the lesions met with in the brain 
to be of the nature of a parenchymatous inflammation, the process being modi- 
fied by the peculiar circumstances of the attack and by the special nature of 
the tissue. 

The history and phenomena of sunstroke are very fully entered upon by 
Arndt, as seen in various stages and degrees of the malady. He particularly 
insists on the very high temperature of the body accompanying it, and on the 
consequent interference with all the vital functions, particularly with the 
destructive metamorphosis of tissue, and the eliniiuatiou of used-up material. 



1870.] Medical Pathology and Therapeutics. 207 

He points out tiftt the blood is loaded with excreted material, that it has a 
black colour, does not coagulate, and is rich in carbonate of ammonia. The 
lungs are congested in their dejicndent parts, and the bronchial mucous mem- 
brane intensely injected and swollen. In the greatly elevated temperature, 
and the many consequences dependent upon it, Arndt finds an analogy with the 
most marked septic diseases. — Drit. and For. Med. Cliirnrij. Rev., Oct. IST'i. 

17. Treatmenf of Cerebral Rheumatism by Chloral. — M. Bouchut, in a 
memoir read before the French Academy of Sciences, says the serious com- 
plication of acute articular rheumatism, called cerebral rheumatism, is only — 
as proved by pathological anatomy and by the ophthalmoscope — a form of 
meningitis. Examination of the membranes of the brain reveals a considerable 
venous stasis with an opaline infiltration of the pia mater, caused by numerous 
leucocytes. The ophthalmoscope, by means of which the developments of the 
alterations in the cerebral substance and in the meninges may be followed in 
the eye, discloses a serous infiltration of the papilla and of the retina adjoining, 
with dilatation of the retinal veins, which represent corresponding changes 
in the pia mater and in the brain. Rheumatism of the brain is ushered in by 
delirium more or less violent, terminating by coma or by asphyxia, sometimes 
very rapid, which may cause death in a few hours. In three cases of this kind 
a cure was obtained by means of hydrate of chloral, given by the mouth in 
doses of from gr. xlv to oi^^- once or twice at short intervals, so as to obtain 
an immediate abatement of the agitation the patients presented. — Dublin Journ. 
Med. Sci., Sept. 1B75, from Gaz. M6d. de Paris, June 26, 1875. 

18. Artificial Respiration in Fulminant Apoplexy. — Some nine years ago 
Prof. ScHiFF, of Florence, in his lectures on the nervous system, announced that 
in fulminant apoplexy consequent on paralysis of the medulla oblongata, arti- 
ficial respiration — never bleeding — was the treatment indicated. This induc- 
tion he had reached after numerous experiments on the lower animals. By 
artificial respiration the blood is saturated with the oxygen, indispensable to 
life, while the pressure of the circulation is kept low, so as to obviate a new 
hemorrhage in the brain. For this reason, to say nothing of the fact that the 
artificial introduction of air can be regulated according to the requirements of 
the case, Prof. Schiff prefers the artificial respiration by means of the bellows 
to the respiration of pure oxygen. 

His assistant. Dr. Corso, describes a case in which the efficacy of the practice 
was well illustrated. A lady having accidentally fallen on her occiput was 
brought into hospital with fracture of the base of the skull. Immediately on 
admittance she was found insensible, with her eyes closed, her face cyanotic, 
the respiration very slow and shallow, pulse small and feeble, and, in fact, all 
but moribund. Artificial respiration was at once practised. After a few 
minutes the heart began to beat with greater frequency and force; in twenty 
minutes' time the natural respiration was re-established, and sensibility re- 
turned. Next day she had improved to such a degree that she could sit up in 
bed and eat by herself. The intellect, however, was not perfectly restored, her 
attempts at discourse being incoherent. 'I'his indication of lesion of the 
cerebral substance increased, till after fifteen days she died. At the autopsy 
there were found fracture of the base of the cranium, hemorrhage on the right 
side extending down to the medulla oblongata, and lesion of the substance of 
the brain. 

The immediate danger in apoplexy lies in paralysis of the medulla oblongata, 
and consequent impairment of the mechanism of respiration. If this patient 
had not had, together with hemorrhage, lesion of the brain, which is common 
to apoplexy, whether spontaneous or produced by an external cause, she would 
(says Dr. Corso) have been saved. IBy artificial respiration time is given to 
the brain and medulla oblongata to recover the shock and resume their func- 
tions, if not perfectly all at once, still in such degree as to maintain life and 
make improvement possible. Even as it was, the patient, but for artificial 
respiration, must have died within a few minutes after entering the hospital. 



268 Progress of the Medical Sciences. [Jan. 

A great future, thinks Dr. Corso, lies in store for artificialVespiration ; pul- 
monary diseases, in particular, seem a fertile field for the practice. — iMiicet, 
Oct. 2, 1875. 

19. Pathology of Chorea. — Dr. W. H. Dickinson read a paper on this subject 
before the Royal jMedical and Chirurgical Society (Oct. 1 2th). At the outset the 
author remarked upon the need of accumulated observations in the present state 
of the patholojry of the nervous system, before it would be possible to know the 
progress of any disease from its origin to its termination. He then proceeded 
to describe the morbid appearances found in seven fatal cases of chorea. The 
cases were related, as nearly as could be judged, in the order of their acute- 
ness, those being placed first in which death ensued earliest. Case 1. A girl 
aged ten years, had acute rheumatism one month before; systolic murmur at 
apex ; no palpitation, but pain in left chest and spine. The attack of chorea 
lasted two days, terminating somewhat suddenly, death being preceded by acute 
pain in lumbar region. 'Jliere was found thickening of edge of mitral valve, 
with vegetation on its auricular border. Intense injection, both arterial and 
venous, in brain and cord, most marked in tlie corpora striata, the arbor vitje 
of the cerebellum, and in the dorsal region of the cord. Traces of perivascular 
erosion widely distributed, and the central canal of the cord was greatly dilated 
(measuring one-seventh of an inch in diameter in the lumbar region), and dis- 
tended by debris of blood and by serous exudation. Case 2. Girl aged ten 
j-ears — third attack, the first of which, four years previously, had been very 
severe. The present attack lasted twenty-one days, the temperature reached 
104.5^, and there was a faint systolic murmur. 'JMie mitral valve was beaded. 
In the nervous centres there was similar evidence of congestion, both arterial 
and venous, especially in the corpora striata, with the addition of superficial 
hemorrhages, and exudation around the arteries of the corpora striata. In the 
cord, besides injection, there were numerous periarterial erosions in the dorsal 
and lumbar regions, especially in the gray matter. Case 3. A boy aged seven ; 
death on the twenty-fourth day. Vegetations on mitral valve. Injection of 
vessels of brain of every class, most about optic thalarai ; some extrusion of 
corpuscles. Injection of cord, and hemorrhage into gray matter of dorsal and 
lumbar regions, symmetrically with regard to the two sides. Case 4. A girl 
aged eight ; chorea following fright received three days before ; no cardiac mur- 
mur; death in a typhoid condition fifty-seven days after the fright. Engorge- 
ment of veins of brain, chiefly on surface and in substance of corpora striata. 
Injection and erosion of the cord, with large hemorrhage (visible to naked eye) ' 
in the anterior cornu in the cervical region, and smaller hemorrhages elsewhere. 
Case 5. Duration fourteen days. Venous injection of brain, especially of 
corpora striata, wherein were also periarterial exudations. Arteries in con- 
volutions near Sylvian fissure, surrounded by blood-crystals and debris. Injec- 
tion and scattered erosions of cord. " Sclerosis" of gray matter in dorsal and 
cervical regions, placed with bilateral symmetry. Case G. Female, aged fifty- 
four; since last attack, thirteen days ; two preceding attacks, the last a year ago. 
Recent injections, such as in other cases, of Ijodies at floor of lateral ventricles 
and of cord. Older changes, periarterial degenerations, and scattered spots 
of ''sclerosis" in auhslavlia perforata, and convolutions at beginning of left 
Sylvian fissure. Case 7. Duration four years. Spots of " sclerosis" numerously 
set in substantia perforata, and gray matter of corpora striata, symmetrically 
with regard to the two sides. In cord large exudations into the gray matter 
and fissures, chiefly in the cervical region. In s|)eaking of so-called " sclerosis." 
the author pointed out that the term was misleading, since there was no indura- 
tion, the change consisting in small round or oval translucent spots, about one- 
hundredth part of an inch in diameter. Having given the above summary of 
fatal cases, he stated that it was enough to show that the changes were remark- 
ably constant in kind and place. In kind the changes were all (allowing 
sclerosis to be so) directly connected with vascular disturbance. The injection 
was general to vessels of every kind, but most marked in the arteries; when the 
sources of exudation or of hemorrhage could be determined, they were always 
arterial ; the degenerations were usually periarterial, and the spots of sclerosis 



1876.] Medical Pathology and Therapeutics. 209 

similarly placed. 'I'hc first visil)le cliaufjo wouKl seem to be injection or dis- 
tension of the arteries, this beinof succeeded by extrusion of their contents, to 
the irritation or injury of the surroundinjr tissues, la plarc the changes affected 
both lirain and cord; the cord perhaps the most severely. Whether in brain 
or cord, the changes on the two sides were generally symmetrical, both being 
often affected at the same spot in the same manner, and nearly to the same 
extent ; and in instances where no symmetry was apparent, a tendency to it 
could be traced, as in the existence of vascular distension on one side corre- 
sponding to hemorrhage on the other. The parts of the brain most usually 
attacked lay between the base and the floor of the lateral ventricles in the track 
of the middle cerebral arteries — the substantia perforata, the corpora striata. 
and the beginning of the Sylvian fissures. In the cord the changes attained 
their maximum in the posterior and lateral parts of the gray matter and in the 
upper portions of the cord. Regarding arterial repletion as the origin of the 
pathological changes, the source of this vascular state was discussed. 'I'he 
embolic theory was shown to be inconsistent with the character and distribu- 
tion of the. morbid appearances, in that in no instance were decolorized plugs 
found in the arteries, and the symmetrical distribution of the changes was 
strongly opposed to embolism. 'J'o elucidate some of the points in question, 
the clinical history of the disease was adduced as represented by a tabulation 
of 22 fatal cases, all examined after death, and 70 cases under observation 
during life only. The prominent fact brought out by these cases was the fre- 
quency of mitral endocarditis in connection with the disease. This existed in 
IT of the 22 fatal cases, while there was stethoscopic evidence of it in 40 of the 
70 non-fatal cases. It was thus shown that endocarditis was associated with 
chorea independently of the frequent origin of the chorea in rheumatism, and 
when the nervous disturbance could be definitely traced to mental causes. 
'I'hus. while in rheumatic cases endocarditis often preceded the chorea, it was 
equally evident that chorea in other circumstances preceded and caused the 
endocarditis. This duplex relation between the nervous and the cardiac dis- 
order was discussed, with the conclusion that chorea was not in any way, 
either embolically or otherwise, a result of endocarditis, though often associ- 
ated with it as having a common origin in rheumatism; while endocarditis was 
continually a result of chorea, set up possibly by the muscular irregularity of 
the heart and the mitral regurgitations thereby occasioned. In conclusion, 
chorea was regarded as depending upon a widely spread hypertemia of the 
nervous centres, not due to any mechanical mischance, but produced by causes 
mainly of two kinds, one being the rheumatic condition, the other comprising 
various forms of irritation — mental and reflex — belonging especially to the 
nervous system. Given the irritant, mental, reflex, or rheumatic, the course 
of the disease had been sufficiently traced in hyperaemia and its results. The 
spots of perivascular change were widely scattered through that large region 
which lies inferiorly to the cerebral convolutions, between the corpora striata 
and the lower part of the cord, the district of the motor and sensory as dis- 
tinguished from the mental functions. The result, chiefly in muscular excite- 
ment rather than in paralysis or loss of sensation, was associated with the 
character of the lesions which were points of irritation rather than planes of 
sections, and calculated not so much to cut off as unnaturally to excite nervous 
function. In looking at the nature of the lesions, proceeding, as they do, from 
vascular distension to perivascular change, it was not possible but to connect 
them with those of a large group of nervous disorders, prominently with those 
of diabetes. In diabetes the changes are of similar origin and character, though 
usually seen at a later stage, and attended with more excavation. They are, 
however, somewhat differently disposed in the two disorders; in both they are 
widely distributed, in diabetes the stress falling upon the brain, in chorea upon 
the cord. Every period of life has its own region of nervous susceptibility : in 
childhood the motor; in adolescence the emotional; in advancing years the 
mental, and, coevally or nearly so, that part of the nervous mechanism which 
instigates glycosuria. Much the same mental impression may make a child 
choreic, a girl hysterical, or a man diabetic ; and thus, both in external origin 
and in the nature, though probably not in the site, of the organic changes, we 



270 Progress of the Medical Sciences. [Jan. 

see resemblances and alliances between nervous disorJers which in their symp- 
toms betray little similarity. — Lancet, Oct. 16, 1875. 

20. Treatment of Chorea hy Ether-Spray and Jce- Water Lotions along the 
Vertebral Column. — Dr. Fabry has brought together in his Thine de Paris, 
April 16, 187.5, No. 107, the cases he saw whilst in Dr. Perroud's wards at 
Lyons of the treatment of chorea by ether-spray. This therapeutic means, 
employed for the first time in 1866 by M. Lubetski. a physician at Warsaw, 
has yielded very satisfactory results in M. Perroud's hands. The ether-spray 
is applied along the vertebral column by means of any spray-producers, espe- 
cially those of Richardson and Marmier Each application lasts from four to 
eight minutes; at the commencement of the treatment three applications /*?/■ 
diem are made, and the number is then reduced to two. Ice produces the same 
effect as ether-spray ; the effects being produced by moving a piece of ice 
along the vertebral column for five minutes. These two methods act on the 
excito-motor point of the nervous centres by their refrigerant revulsive action. 
— London Med. Record, Nov. 15, 1875. 

21. Nitrite of Amyl in Xervous Cephalalgia. — Dr. Lithgow states {Lancet, 
Oct. 16, 1875) that he has been in the habit of using nitrite of amyl in nervous 
headaches as recommended by Sir J. Y. Simpson, and where due care was 
taken in the selection of cases, he has never known it to fail to produce entire 
and almost immediate relief. " In several instances," he says, " I have had to 
increase or repeat the dose, but, as a general rule, two drops have been suf- 
ficient. 

" 1 place two drops on the palm of the patient's hand, and, quickly diffusing 
these with ray finger over the palmar surface, I tell her to cover her mouth and 
nose with her hand, and to inspire deeply and quietly. No time should be lost 
after the nitrite is dropped on the hand, as it evaporates rapidly. The patient 
should be seated while inhaling, as the peculiar effects of the nitrite are pro- 
duced almost instantaneously, and may occasionally alarm a very nervous or 
hysterical female. Fortunately these symptoms last a very short time — gene- 
rally less than two or three minutes^ — and with their cessation the pain almost 
invariably ceases. Two drops may be given as a draught in water, instead of 
by inhalation, but I have found the latter mode much more satisfactory. 

. . . " Used as I have just recommended, I don't think there is the slightest 
risk in its administration ; but, owing to the temporary palpitation of the heart 
produced in most patients, care should be taken in administering it in cases of 
organic cardiac disease, etc. Should any excitement or other alarming symp- 
tom occur, cold affusion to the head, face, and chest, with a free supply of 
fresh air, are the proper means to use, but I have never had occasion to do so. 
The nitrite (which is cheap) should be procured from reliable makers only, and, 
as an economic suggestion. I recommend any one using it to preserve it in a 
stoppered glass bottle, having an additional glass cap-cover." 

22. Tincture of Gelseminum in Neuralgia. — Dr. Spencer Tuomsox extols 
[Lancet, Nov. 6, 1875) the beneficial effects of tincture of gelseminum in 
neuralgic pain of the jaws generally, and of the teeth and alveoli more parti- 
cularly. He gives it in doses of twenty minims, and if this does not afford 
relief in an hour and a half or two hours, he repeats the dose. He has rarely 
had to order a third dose. 

23. Bromide of Potassium in Epistaxis, Uterine Hemorrhage, and Coryza. 
— M. Ad. Gexeiil. in a communication to L' Union Medicate (Nov. 4, 1875), 
relates four cases of epistaxis in which the hemorrhage was promptly arrested 
by the injection into the nostrils of a saturated solution of bromide of potas- 
sium. Two or three injections sufficed. At the same time he gave the bromide 
internally. He has also arrested uterine hemorrhage in one case by inserting 
a dossil of lint which had imbibed a saturated solution of the same salt. He 
considers this medicine given internally very useful in moderate uterine hemor- 
rhage. He cured himself completely iu six hours of a severe coryza by two 



1876.] Medical Pathology and Therapeutics. 271 

ini«'c-tions into his nostrils of a saturated solution of the hromitle, ami he claims 
tit have saved the life of an iufaut three months of age by the same treatment. 

24. Treatvietif of Spasmodic Aslhmd hu (he Snbcutaveous Injection of Mor- 
phia. — Dr. J. Kkith Axdkrson states {Practitioner, Nov. 187.")) that he has 
treated now twelve cases of spasmodic asthma by subcutaneous injections of 
morphia. '• and the result in all cases has been a complete and perfect relief from 
the embarrassment of the respiration The rapidity with which the distressing 
symptoms are controlled is very striking. In from five to ten minutes after the 
injection has been administered, the patient finds himself well per salftnn. 
There is no perceptible interval between the agony of breathlessness of one 
moment and the perfect calm and rest of the ne.xt. I have seen a man who 
had been labouring to speak — jerking out his words syllable by syllable — 
suddenly rise to his feet, and, with easy and unembarrassed resjjiration, finish 
his remarks in an uninterrupted flow. So soon as the morphia gets fairly into 
the current of the circulation, that moment the spasm is relaxed, and the 
patient is at peace, with Dothing but his exhaustion to testify to the suflFerings 
he has undergone. 

" I'he dose which I have used has been in all cases one-sixth of a grain of the 
hydrochlorate of morphia in a strong solution. In no instance has its use been 
followed by any more unpleasant result than slight nausea. This effect has 
not occurred on more than one or two occasions, from which I infer that the 
relaxation of spasm is by no means dependent on its production. 

"In no attack has there been any tendency to the recurrence of breathlessness 
after the first effects of the morphia have passed off. I have been inclined to 
believe that its use has been succeeded by an unusually long immunity from 
further attacks. 

" I may add that those who have once experienced the rapid and unfailing 
relief of the subcutaneous injection are no longer content to await the action 
of the more uncertain remedies to which they had formerly been accustomed 
to resort." 

[Three years ago the attention of the readers of this Journal was called by 
Dr. Moss of Chestnut Hill, Penna., to the efficacy of this treatment in autum- 
nal catarrh.] 

2.5. Rheumatic Pleurisy. — The Gazette des Hopitaux, of July 17 last. No. 
83, contains a clinical lecture delivered by Professor Lasegue, on a case of 
pleurisy at La Pitie. The patient was a tall, stout-built, almost plethoric 
Alsatian, aged thirty years — a policeman, exposed to cold and wet in his voca- 
tion. On March G he had a rigor, followed by feverishness and copious perspi- 
rations. Almost simultaneously he felt acute pains all over the right side of 
the chest, intensified by movement and respiration. Decubitus on the left side 
and cough were almost impossible. Even deglutition was painful. After some 
days, the pains persisting, though over a more limited area, he entered the 
hospital, still suffering considerable pyrexia ; and pleurisy was diagnosed, over 
a very limited space, near the base of the right lung, behind. The stabbing 
pain was most intense just below the nipple, and was very severe. Wet cup- 
ping over the affected spot gave great relief; the next day, the ninth of the 
attack, there was but little pain, the effusion was less, the feverishness gone. 
The diagnosis ^fi-ds rheumatic pleurisy. M. Lasfegue thinks that pleurisy of a 
rheumatic nature may be distinguished by its site, its severity, its extent, and 
its duration. 'J'he inflammation is limited to the parietal pleura, the subcostal 
and intercostal yi6/-0Ms tissues. The pain is localized, and is extremely severe, 
and increased by movement, like the pains of a rheumatic joint. It may, in- 
deed, alternate with, or be metastatic with, a joint-affection. The attack is 
seldom prolonged very greatly, and the prognosis is favourable. The fever 
runs high in these attacks. On the other hand, in pleurisies which commence 
with the lungs or bronchial tubes, which one may therefore call visceral pleu- 
risies, broncho- or pneumo-pleuritis, the fever is less, the stabbing j)«/« is less ; 
there is more difficulty in localizing them, and though the pain does not last so 
long, the disease lasts longer, and is of less favourable prognosis. It is not. 



212 Progress of the Medical Sciences. [Jan. 

however, denied that a rheumatic pleurisy may involve the lung's, and perhaps 
bronchial tubes also, after it has existed for some time. Hence it is important 
to distinguish the two forms early. In the later stages of both, thoracentesis 
may be necessary. M. M6hu, chief pharmacien at the Hospital Necker, has 
shown that ivhen a pleuritic eff union in found lo be rich in chlorides, and other 
mineral salts, it seldom recurs after tapping; whilst those which leave little 
saline residue when evaporated to dryness, are not only reproduced, hut com- 
monly end fatally. 

It is rare, however, for a pleurisy of rheumatic origin to need paracentesis. 
M. Lasfegue says that once, when in doubt as to the nature of a paraplegia 
with acute spinal pains, and pains round the loins, the supervention of a pleurisy 
of this sort enabled him to diagnose rheumatic meningitis of the cord, and to 
give a hopeful prognosis which was fully justified by the event. — London Med. 
Record, Nov. 1.5, 1875. 

26. Treatment of Acute Sthenic Pnerunonia with Vercdrum. — The course 
of pneumonia appears to be as little influenced by veratrum as by other 
drugs. In sixty cases treated partly with tincture of veratrum album, and 
partly with that of veratrum viride, in Prof. Duchek's wards at Vienna, Dr. 
Th. Sidlo has arrived at the following results : 1. In the majority of the cases 
there was either a temporary or a permanent reduction of the temperature, and 
of the frequency of the pulse, but in the remainder the veratrum had not the 
slightest appreciable influence. 2. The effect on the fever, whatever its degree, 
was not attended by any corresponding reduction of the normal duration of. the 
febrile process, nor was the typical character of primary lobar pneumonia 
obliterated by the treatment ; on the contrary, it became moi-e clearly pro- 
nounced during it. 3. Minor variations in the febrile symptoms were proved 
to depend not on the action of the veratrum, but on the character and amount 
of the inflammatory process in the lungs. Over the latter the drug exerted no 
action whatever ; it increased, diminished, and terminated, to all appearance 
just as if nothing had been given. 4. It was found that vomiting, collapse, 
and other unpleasant effects more often followed the use of veratrum album 
than of veratrum viride, but in neither case did they appear to modify either 
the fever or the physical condition of the inflamed lungs. — Med. Times and 
Gaz., Sept. 25, 1875, from Dcutsches Archiv fur Klin. Med. 

27. Can Tubercxdar Matter or the Flesh of Tnhercidous Animals commu- 
niccde or excite Tubercular Disease if taken as Food ?—VtoL Gurlach, of 
Berlin, has made an elaborate experimental research on this question. 'J'he 
method employed by him was to introduce into the stomach of the animal one 
or two doses of tubercular matter. The effects, if any, were observed ; and 
if the animal did not die from these, it was killed some weeks or months after 
the administration of the substance, and a post-mortem examination was made. 
The weak point of the paper appears to be that no details are given as to the 
hygienic conditions under which the animals lived while under observation. 
It is well known that tubercular formations are very common among domestic 
animals kept in close confinement. So great is the importance of the inquiry, 
not only from a hygienic point of view, but also as relating to the etiology of 
tubercle, and its transmissibility in the human race, as to render a repetition 
of these experimen+s desirable. The conclusions arrived at by Professor 
Gerlacli may be summarized as follows: — 

1. There is a specific virulent material in tubercle, and many of the symp- 
toms of tubercular disease are due to the absorption of this virus. 

2. 'I'his virus exists in tubercle in all its stages, but apparently in greater 
intensity in cheesy masses. It is found in recently formed tubercle, and in 
miliary tubercle. 

H. 'I'he infection begins first in the mucous membrane of the mouth, and if 
the tubercular matter be in contact a sufficient length of time with the mucous 
meml)rane of the alimentary canal, it may communicate the disease to the 
whole lymphatic system. 

4. While tubercular disease has special characters in different animals, all 



1870.] Medical Patholojiry and Therapeutics. 273 

tubercular mattor. wlicii introtlnccd into tlic alinieutary canal from one species 
to another, is more or less virulent. 

5. The tul)ercular matter of l)ir(ls. especially that of the coninioii hen, is very 
virulent, and is identical in its action with that of mammalia. 

6. The (ilirous tubercle of horses, without a trace of cheesy formation, is 
just as infectious as the miliary tuhercle of cattle. 

7. The flesh of tubercular animals is also infectious, though in a much less 
decree than tubercle itself. 

H. 'I'ubercnlar material cooked for a quarter to half an hour, is still infectious, 
thouirh in a much less deiirce than that not cooked. 

9. The effects of poisoning by tubercular mutter taken into the alimentary 
canal are irritation of the mucous membrane both of the alimentary and re- 
spiratory tracts, enlargement and tenderness of the lymphatic gl.iuds, enlarge- 
ment of the bronchial glands, and the formation of tubercle in the lungs and 
other organs. 

(ierlach used in these experiments sheep, wethers, lambs, swine, sucking 
pigs, heifers, calves, a horse, rabbits, dogs, guinea-pigs, an ass. goats, and 
pigeons. — Edinburgh Med. Jonrn., Oct. 187.1. from Archiv filr Wissenschufl- 
liche uudprafische Thetrheiikunde, lid i. lit. 1. 

28. Ergot iu Ho'moptysi.'i. — Dr. Jas. M. 'Williamson states [Lancet, Nov. 
13th. 187.t) that he has administered ergot in fifty cases of hremoptysis occur- 
ring in ditl'ercnt stages of phthisis. The amount of hemorrhage varied from 
abundant bright streaks on the sputa to the expectoration of several ounces 
of blood. As the cases all occurred in hospital practice, very little time was 
lost between the advent of the haemoptysis and the exhibition of the remedy. 
The ergot was invariably given by the mouth and in the form of the liquid 
extract. Much has been said about the success of the subcutaneous injection 
of ergotin and its superiority to this plan, but since there was no difficulty in 
any of the cases iu administering a draught, and as the drug acted in most 
instances with a promptitude which was sufficiently satisfactory, the hypodermic 
method was not employed. Forty-minim doses of the liquid extract may be 
given twice within the first hour, and, guided by the results, at least every two 
hours afterwards, the dose being diminished and given less frequently as the 
hemorrhage subsides. He has never observed any disagreeable effect follow, 
even upon the administration of large quantities within short periods, but. 
as a general rule, if four or five full doses make no distinct impression upon 
the hemorrhage, the remedy should be abandoned for another. Care should be 
taken to use a fresh and sound preparation of the ergot. 

Out of the 50 cases, the drug rapidly checked all bleeding in 44 instances. Of 
these, IG were women and '28 men, and in at least one-fourth of the number the 
haemoptysis merited the term profuse. In 40 of the 44 cases it was the first 
and only remedy given ; in 2 others it was successful after a mixture containing 
gallic acid, alum, and dilute sulphuric acid failed ; iu another it was effectual 
after acetate of lead with opium proved useless; while in the remaining in- 
stance it repressed the bleeding after both of these plans were unavailing. 
The ergot was inefl'ectual in G cases. 

in three of the cases of failure gallic acid equally failed. Over gallic acid 
ergot has the distinct advantages of never causing griping or constipation, 
and more especially of not interferring with a liberal use of milk. The larger 
proportion — equivalent to 88 per cent. — of the cases in which ergot succeeded, 
not only testifies to its great value and claims for it our confidence, but also 
strongly justifies the recommendation that it should be the first drug tried in 
all cases of ha?moptysis. 

29. Contracted Pupil in Heart Disease. — Prof. Giovanni has stuilied with 
care three cases of advanced organic lieart disease accompanied wiih bilateral 
myosis, from which he draws some interesting conclusions. All three were 
accompanied by severe dyspnoea, continuous or recurrent. One was a case of 
mitral narrowmg and insufficiency ; the second, a case of aortic narrowing, with 
valvular insufficiencv ; the third, aortic narrowing, with mitral insufficiency. 

No. CXLL— Jan. 1876. 18 



2T4 Progress of the Medical Sciences. [Jan, 

In all three, there was constant bilateral myosis ; in two, this symptom was 
more marked when the dyspnoea was more urgent. Since Pourfourd, Dii Petit, 
Bernard, and Biffi demonstrated the influence of the sympathetic on the pupil, 
the action of aortic aneurisms and of other tumours on the pupil has lieen 
studied. Eulenberg, Guttmann, and others, have shown that all affections 
which produce compression of the sympathetic in the neck are followed by 
pupillary stenosis. The author has not found this symptom mentioned in iso- 
lated cardiac affections. In order to determine the clinical value of myosis of 
cardiac origin, its origin and mechanism must be studied. It is a paralytic 
myosis. It may arise from three sorts of lesion : 1, lesions of the cervical cord ; 
2, lesions of the superior cervical ganglia ; 3, of the terminal filaments of the 
sympathetic which go to the radial fibres of the iris. We must here dwell on 
the lesion of the superior cervical ganglion. The author has examined with 
the microscope the sympathetic and many sections of the cervical spinal cord 
of the patients in question. He has found great hypera^mia of the ganglia of 
the sympathetic, with more or less intens(> infiltration of the lymphoid elements. 
At the same time, the tissue of the ganglia was softer and more infiltrated with 
fluid than in the normal state. 'I'he upper part of the cord presented no simi- 
lar condition; nor was there any reason to admit an isolated lesion of the ter- 
minal sympathetic nerves of the iris. These different lesions are the conse- 
quence of the stasis of the blood produced by the state of the heart. They 
exist, probably, in all patients of this class, but are not always manifest. The 
disorders which have their source in the sympathetic are comparable to those 
which proceed from the encephalon or from the spinal marrow. In certain 
patients with cardiac disease, cerebral excitement is found; in others, somno- 
lence. Myosis has a very distinct significance ; it does not only indicate stasis 
of the blood, but a profound lesion of the ganglionic cells, thenceforth para- 
lyzed. The ganglionic lesion affects equally the heart and the lung, to the in- 
nervation of which the ganglionic cells contribute. The cardiac activity and 
pulmonary circulation are therefore more seriously affected than in other cases, 
when myosis exists. The author draws from these facts the following conclu- 
sion from the point of view of prognosis. Myosis in affections of the heart is 
a symptom of very grave prognostic value. It announces the presence of a 
lesfon of the ganglia of the sympathetic, which tells upon the heart itself and 
the lungs. — Brit. Med. Journ., Sept. 25, from Aiinali Universali tli Medicina. 

30. Paracenfe.'iis of the Pencardium. — M. H. Roger has made an elaborate 
report to the French Academy of Medicine on a case of puncture of the pei-i- 
cardium communicated by Dr. Chairo, in which he gives an instructive account 
of pericardial effusions and their surgical treatment. The results of paracen- 
tesis of the pericardium, Mr. Roger states are disastrous. He is able to find 
but five cases of incomplete and one of complete cure effected by it. He con- 
cludes that notwithstanding the progress of operative surgery, the puncture of 
the pericardium is an extremely hazai'dous -procedure ; notwithstanding, how- 
ever, its real danger, it may be resorted to in certain cases, rather as a palliative 
measure than with the hope of effecting a cure. — Gazette Hebdom. de M6d. 
et de Chlnu-ij., Nov. 5, 1875. 

31. On Aortic Aneurism in the Army, and the conditions associated with 
it, — Mr. F. H. Vei-ch read an interesting paper on this subject before the 
Royal Medical and Chirurgical Society (Nov. 23). The object of the paper 
was to endeavour, by deductions made from a series of post-mortem examina- 
tions conducted at the Royal Victoria Hospital, Netley, to place certain fea- 
tures of causation and {)athology of aortic aneurism upon a basis of stability. 
The average death-age was 32 years ; average period of service performed by 
the soldier. 12 years; average duration of the lesion, l^V years. In five in- 
stances, the dilatation was multiple, the largest number of aneurisms in any one 
case being four ; and, in two instances, an innominate aneurism was superadded 
to the aortic sac. The lesions (otherwise than the sac itself) observable in the 
bodies were arranged under two heads ; («) those mechanically produced by 
the aneurism ; and (/>) those indicative of a diathesis or general internal agency 



1876.] Medical Pathology and Therapeutics. 275 

generally syphilitic. Tlie author stuted that statistics of aortic aneurism in 
the army showeil that tlie disease was not peculiar to climate, station, or occu- 
pation, nor connected with ape or any condition of system brought about by 
length of service ; and upon this negative basis was superadded the positive 
basis furnished l)y the morliid anatomy and life-history of the cases comprised 
in the paper. The deductions arrived at were placed in the form of two propo- 
sitions, the first of which referred to the condition of the vessel, and was as 
follows: " 'I'he aneurismal tumours are associated with, and preceded by, a 
diseased condition of the contiguous layers of the internal and middle coats of 
the vessel : a tissue-growth, terminating in degeneration, which, by impairing 
the elasticity and contractility of the walls, allows their expansion and dilata- 
tion under the tension of normal arterial blood-pressure, or this abnormally in- 
creased by any cause." The term " atheroma" was regarded as unsatisfactory. 
as it expressed one possil)le phase only — that of degeneration ; and allowed the 
accumulation, under the same nomenclature, of structural changes, divergent 
in origin and progress. Two forms of deterioration were embraced by it ; one 
a distinct tissue-growth — an endarteritis, an active lesion — having, as one of its 
sequeUc, the aneurismal sac ; the other, a mere opacity or occasional fatty 
degeneration of the inner surface of the vessel — a passive phase — followed, 
apparently, by no very deleterious results between eighteen and forty years of 
age, the period of the soldier's service. 'I'he pathological chain of continuity 
between the aortic disease, characterized by a tissue-growth, and the aneurismal 
sac, was complete ; and hence the important problem in etiology was to eluci- 
date the exciting agencies in the development of the endarteritis of the internal 
and middle coat ; and these were given in the second proposition as follows ; 
'•These two forms of textural derangement of the aorta" (the two spoken of as 
included under "atheroma") "are dissimilar in origin and causation. The 
limited passive opacity is connected with long-standing diseases of various 
kinds, inducing a diminished vitality of the system at large; the structural 
growth is. in the major number of instances, associated with syphilis, and, in a 
minor degree, with rheumatism and alcoholism as causation. Hence it follows 
that, as the latter phase is the commencement of that pathological sequence of 
events under one aspect, terminating as aneurism, the means for the prevention 
of the aneurismal tumour must be essentially directed towards the elimination 
of these special exciting agencies." The 34 cases of aneurism analyzed stood 
as follows. In 50 per cent., the subjects were saturated with the syphilitic 
virus, and had no other diseased conditions of importance; in 14 per cent., 
syphilis was probably present, but not beyond doubt; in 5.8 per cent., there 
was acute rheumatic diathesis ; in 5.8 per cent., excessive intemperance ; in 2.9 
per cent., syphi'lis, rheumatism, and alcoholism combined ; in 17.64 per cent.. 
there was absence of information as to any known conditions ; and in 2.9 per 
cent., no associated condition could be elucidated. A table was also given to 
show the associated systemic conditions of the aortic lesion, as exemplifled in 
117 cases as follows : 46. 1 per cent, in undoubtedly syphilitic subjects ; 6.8 
per cent, probably syphilitic, but not beyond doubt ; 21.3 per cent, in phthisi- 
cal subjects; 14.2 with no records for determination: 5.9 with heart-disease; 
5.7 with various other diseases individually small. The table included both 
forms of the aortic disease ; the active growth as well as the passive degenera- 
tion ; but showed a great preponderance with syphilis. The lesions were 
separated as follows. In 56 cases of syphilis terminating fatally through special 
lesions, 60.7 per cent, illustrated aortic nodulation, the major part of a severe 
type ; and in about one-third of these {i. e., 18 out of 56). the vessel-disease 
had led to dilatation, more or less pronounced : that is to say, were in the 
infantile stage of aneurism. Adding these infantile aneurisms, and including 
one infantile aneurism subsequently mentioned as due to the acute rheumatic 
diathesis, to the 34 of this paper, the total was 53 ; and of these, 66 per cent, 
occurred in subjects infected with syphilis, but with no other diseased condi- 
tions to neutralize the deductions. Again, in 106 post-muiiem examinations, 
the non-existence of syphilis was fairly deducible, and the following results were 
obtained. Five cases of aneurism were present, which were included in the 
table under acute rheumatism, intemperance, and no known cause. The aortic 



276 Progress of the Medical Sciences. [Jan. 

disease in one instance was severe, and had led to dilatation, in an acute rheu- 
matic diathesis with preat intemperance ; in five, the inner wall of the vessel 
was corriiffated. but not dilated; three were phthisical : one had alcoholism: 
one had aortic valve-disease: in 29, the lesion had the form of atheroma, or 
mere opacity; and of these. 15 were associated with phthisis, and the remainder 
■with renal affections, dysentery, diabetes, scrofula, lupus, and cancer, in nearly 
ecjual proportions. The author inferred that the syphilitic virus must be re- 
garded as a very potent cause of the arterial lesion, and its sequel, aneurism ; 
but not as the only one. for the acute rheumatic poison and alcohol must be 
regarded as minor agencies. The chest-constrictions to which the soldier was 
liable from accoutrements, pack. etc.. acted as fostering influences to the dis- 
eased conditions et gendered by syphilis, rheumatism, and alcoholism, probably 
inducing dilatation in the deteriorated vessel, though no such result might 
ensue under ordinary circumstances, and under such amounts of physical exer- 
tion as pertained to the civil portion of the community. With regard to the 
adoption of preventive measures against aneurism, the author remarked that 
attention must be primarily directed to the suppression of the causes of the 
aortic disease, notably syphilis ; and, secondarily, against the conditions of 
dress, etc.. whicli assisted in its development. — Brit. Med. Jonrv., Nov. 27, 
1875. 

32. Digf'i^tive Pou-er r,f the Gastric Jiiice iv Dr/spfipsia. — In a paper bearing 
the above title, read at the meeting of the German savants at Gratz ( Wie?i. 
Med. Zeiiuiig). Prof. Leube. of Erlangen. observed that it is well known that, 
in order to render the process of digestion regular, a certain amount of the two 
constituents of the gastric juice — hydrochloric acid and pepsin — must be pre- 
sent, dy.spepsia resulting where this is not the case. He has convinced himself 
that, in the majority of cases in which this is produced, a deficiency of the acid 
is the cause of such disturbance of digestion. A very minute quantity of pepsin 
will suffice for the digestion of a large amount of albumen, provided a sufficient 
quantity of acid be present: but for the actual demonstration that the diffi- 
ciency of the acid is the cause of the difficulty, properly directed experiments 
have hitherto been wanting. Prof. Leube has. however, contrived a simple 
procedure for this purpose. Having prevented the person to be experimented 
upon from eating anything the previous evening. ne.\t morning he washes out 
the empty stomach with some lukewarm water, which is found to be in a clear 
and neutral condition. About 750 grammes of barley-broth ( Grarq>r7)s>ippe) 
are then administered, care being taken that the individual does not masticate, 
so that no saliva may enter the stomach : and. after ten minutes, this is with- 
drawn by means of the stomach-pump, filtered, and examined for an acid re- 
action. 'I'he experiment was tried on four persons — one in good health, two 
dyspeptics, and a drunkard. The degree of acidity was estimated by a solution 
of soda, thirty parts being required for neutralization in the healthy person, and 
nearly one-half that quantity in the dyspeptics, tiie fluid being neutral in the 
drunkard, who was suflering from chronic stomach disease. Microscopic slices, 
of exactly the .«ame size, of a hard-boiled egg were introduced into the fluid 
extracted from the stomach, and artificial digestion set on foot at a tempera- 
ture of 3.5^ C. In about six hours the slices were entirely dissolved in the fluid 
derived from the healthy stomach. In one of the dyspeptics the albumen re- 
mained quite unchanged at the end of fourteen hours, and was visibly and 
plainly acted upon only after twentj'-four hours. In the drunkard no influence 
was recognizable at the end of three days. In all these instances the addition of 
small quantities of the acid greatly expedited digestion, though in very different 
degrees. 

The conclusion to be drawn is, that in cases of disturbed digestion the mucous 
membrane of the stomach secretes less acid than in health, and that the diges- 
tive powers of the organ can be strengthened by administering this substance. 
As an example of what may be done in this way. there may be mentioned the 
case of a patieut suffering from dilatation of the stomach, in whom the contents 
of the organ removed by the pump every evening always exhibited flesh-food 
eaten seven hours previously iu an undigested condition. When, however, eight 



1876.] Medical Patholoj^y and Therapeutics. 277 

drops of acid were piven in ;i trlass of water two hours after eatiiiE^, very little 
food was t'oimd to l»e un(lia;e.*ted in the eveniD»r ; and when a second do.se of 
ei«:ht drop.s of the aci<l was ijivi'ii two hours alter the first, complete di^^estion 
was quite secured. When, therefore, iu dyspepsia, the analysis of symptoms 
is obscure, the stomach-pump or tulu' should He resorted to, and when si.\ or 
eight hours after a meal there :\re still found remains of food, and especially of 
ttesh-food. the acid should be experimentally administered. The tube employed 
should be thirty centimetres in length. — Med. Times and Gaz., Nov. 6, 1875. 

33. Diabcfh- Phnsphalurifi. — M. J. Tkissikr, of Lyons, has recently published 
a monograph, the object of which is to show that there exists a grave constitu- 
tional state signalized by polyuria, wasting, and other symptoms of diabetes 
without the presence of sugar in the urine, but with a large e.xcess of earthy 
phosphates. The normal (piantity of phosphates excreted in twenty-four 
hours is about ten to twenty grains, but in this affection the salt has been 
observed to reach from four to ten times that amount. The cases of phos- 
phatic polyuria were first observed by M. Teissier p^re, two or three years 
ago, in which there were the constitutional symptoms of diabetes, with the 
passage of large quantities of urine, but no sugar; the specific gravity being 
low (about 1012), and the amount of phosphates being largely in excess of 
the normal. In one such case, in which there was as much as 450 grains ex- 
creted per diem, the patient was attacked with neuro-retinitis and subretinal 
oedema, folloivtd by albuminuria. The albuminuria diminished, but the phos- 
phaturia continued, so that the case is compared to albuminuria complicating 
diabetes. Another case is given in which traces of sugar as well as of albu- 
men occurred in the course of the affection, but the excretion of phosphates 
persisted. The author inquires whether " diabetes insipidus" may not be 
phosphatic polyuria. It is worthy of note that Dr. Dickinson, in his recent 
work on Diabetes, records excess of phosphates in the insipid form of that 
disease. 

M. Teissier further points out, in confirmation of his view (which he expresses 
very cautiously), that there may be a " phosphatic polyuria resembling dia- 
betes," that this condition leads to grave disturbances of nutrition, notably 
cataract, in the same manner that diabetes does. Pie has analyzed the urine 
in many cases of cataract, and in some has found excess of phosphates in 
the urine. He gives an outline of three cases of double cataract in which 
phosphaturia was present, in all of which operative interference led to ill 
results, and points out that in none of these cases was there any disease of the 
osseous or nervous system, while the fact of the cataract being double indi- 
cated some diathetic state. He affords no explanation as to the starting point 
of the affection, but contents himself with propounding the question that it 
may be due to over-acidity of the blood favouring the solution of phosphates 
in the economy, or to a morbid activity of the nervous system by which more 
phosphates are used up in the nutrition of the nervous centres. — Lancet, Oct. 
9, 1875. 

34. Boracic Acid in the Treatment of Ringioorm. — Surgeon-Major Wat- 
son reports in the Indian Medical Gazette that he has lately employed boracic 
acid with very great success as an external application in the treatment of the 
dermatophyta or vegetable parasitic diseases of the skin. He was induced to 
try this remedy from witnessing its employment as an antiseptic in the Edin- 
burgh Infirmary wards. The diseases in which he has hitherto used boracic 
acid have been the different forms of tinea (T. tonsurans and circinata), and in 
that very troublesome form of the disease which afJects the scrotum and inner 
side of tlie upper part of the thighs of many Europeans in India. Dr. Watson 
declares that the external application of a solution of boracic acid acts like a 
charm in such cases. An aqueous solution of boracic acid of a drachm to the 
ounce, or as much as the water will take up at ordinary temperatures, is em- 
ployed. The affected parts should be well bathed with the solution twice daily, 
some little friction being used, and it should not be wiped off, but allowed to 
dry on the part. The remedy is said to be so simple, cheap, and efficacious, 



278 Progress of the Medical Sciences. [Jan. 

that it has only to be once used to be preferred to all other remedies of the 
same class. — Lancet, Nov. 20, 1875. 



SURGICAL PATHOLOGY AND THERAPEUTICS. AND 
OPERATIVE SURGERY. 

35. Influence exerted hy prior Lesions of the Liver on the Progress of Trau- 
matic Lesions. — Prof. Verneuil read an interesting paper on this subject 
before the recent Congress held at Brussels. He proposed, he said, to demon- 
strate that wounds and operations in the subjects of an affection of the liver 
are often followed by grave consequences. This idea, which he brought before 
a former Congress in 1867, and which some of his pupils have since illustrated, 
was first suggested to him by the perusal of a remarkable paper published by 
Dr. Norman Chevers in 1845, which has excited too little attention. Chevers 
has proved to demonstration, as regards renal affections, that they exert a most 
unfavourable influence on traumatic lesions, stating, at the same time, that he 
possessed only imperfect data concerning the influence of the liver and spleen. 
The numerous facts that have come under M. Verneuil's notice enable him to 
state that the liver exerts as unfavourable an influence as the kidney. The 
three points to be noted are the hepatic lesion anterior to the accidental or 
surgical wound, the nature of this wound itself, and the kind of accidents that 
ensue. M. Verneuil has met with — first, most of the aff'ections of the liver 
(cirrhosis, steatosis, waxy or amyloid degeneration, old perihepatitis, secondary 
neoplastic deposits, biliary gravel, and hydatid cysts) ; secondly, with a great 
variety of surgical lesions as regards seat, extent, and gravity (compound frac- 
tures of the leg, fractures of the cranium, amputations of the thigh and leg, 
excision of the hip, kelotomy, fistula in ano, paracentesis, ablation of tumours, 
etc.); and thirdly, with nearly every traumatic complication (hemorrhage, 
diffuse inflammation, septicaemia, pya3mia. etc.). 

In face of this triple enumeration, M. Verneuil has put the question to him- 
self, whether a given hepatic affection corresponds to a determinate accident, 
or whether a wound received by a sufferer from hepatic disease engenders any 
complication in preference to others. As far as his experience has gone, he 
has found that any lesion of the liver is able, on the occasion of any kind of 
wouud, to provoke indifferently one or other of the accidents enumerated above ; 
and that, reciprocally, any of these accidents may exhibit themselves in all 
hepatic patients the subjects of wounds. In the mean time, awaiting more pre- 
cise knowledge, he thinks that it is still very useful to be aware that in these 
cases the traumatic centre has a chance of giving rise to an early or late 
hemorrhage, or of being invaded by phlegmon or gangrene, and also to know 
that intense and rapid phlegmasia} may become developed in the liver itself or 
in the organs that surround it. 

" I wish now to demonstrate that the above-named accidents have depended 
upon the anterior hepatic affection, and that this consequently has principally 
led to the fatal termination. I am well aware that such accidents may be 
manifested without any anterior hepatic affection having existed in the wounded 
person, and that all persons who have been the subjects of disease of the liver 
do not die as a consequence of their wounds. It is not less beyond doubt that 
the subject of a crushed limb may succumb to pyaemia or septiotemia with a 
sound liver as well as with a diseased one. But when a man suffering from a 
simple fracture, and denying having any disease, is seized on the sixth day with 
vomiting and icterus, and dies on the nineteenth day of an hepato-peritonitis. a 
cirrhosis being found at the autopsy, is it possible to deny that it is by the liver 
he has died ? 1 have been naturally greatly impressed and convinced by these 
facts, in which the insignificance of the injury rendered death absolutely im- 
probable, and where scarcely anything existed to explain it but the mischievous 
influence of the anterior hepatic affection. Such influence, moreover, seems 



1876.] Surgery. 279 

easy of explanation. We know how coniinon in hepatic subjects are sponta- 
neous hemorrhujres, diffuse, phlegmonous, and uangreiious inflammations, an;e- 
raia. and the cachectic condition, pleurisy, peritonitis, etc.; and what is there 
surprising that a traumatic focus should become, in these predisposed subjects, 
the seat of local accidents, and that general and distant accidents should be 
manifested in these same sulijects under the influence of the provocative action 
of traumatism ? It may still be objected that tiie above accidents only appear 
spontaneously or become serious in acute and very advanced liver disease, and 
yet a good many of these wounded hepatic patients seemed at the time of re 
ceivinir their wounds to be in satisfactory health. But do we not know that 
traumatism, however slight, excites in the entire economy sometimes a general 
perturbation, and sometimes, by a kind of selection of the weak point {locus 
miuiiris resistenticv), a sudden and violent asrgravation of lesions that are only 
slight or that slumbered? The affection of the organ that is suffering becomes 
agirravated, and its progress redoubtable." — Med. Times and Gazette, Oct. 16, 
lb75. from Gazette Bebdomadaire, Oct. 8, 1875. 

36. Chloralasa Local Application to Ulcerff. — Mr Lucas, of Guy's Hospital, 
commenced the use of chloral among his out-patients in August last, for cases 
of sloughing wounds and fetid ulcers, and being pleased with the result, he has 
since given it a somewhat extensive trial in the wards. The effect of the local 
application of chloral appears to be that of a powerful stimulant and disinfect- 
ant; it has no soothing or sedative effect upon the part to which it is applied, 
but, on the contrary, gives rise to considerable pain, which lasts some time; 
nor does it. even when used over a very extensive surface, ever become absorbed 
in sufficient quantity to act as an hypnotic. Whether it is taken up into the 
circulation or not matters little, since the quantity used as a local application 
is so small compared with the dose administered as an internal remedy, that 
were the whole of the drug applied to find its way into the blood, the quantity 
absorbed would still be very much less than that of an ordinary sleeping-draught. 
Its local application is, therefore, eminently safe and free from the dangers which 
sometimes follow the use of opium lotion or carbolic lotions long continued. 
Mr. Lucas has used solutions of various strengths, that which he has found 
most useful being a solution of four grains of hydrate of chloral in an ounce of 
water. 'Vhe application of a lotion of this strength is, as we have just stated, 
often attended with considerable smarting, which may last a quarter of an hour, 
but the smarting becomes less at each subsequent application. In cases where 
the patients have complained much of the smarting, the lotion has been diluted 
to the proportion of three or two grains to the ounce. The treatment of foul 
sloughing ulcers by means of chloral lotion has been attended with great 
success, the surface of the sore quickly cleansing and assuming a healthy 
appearance, whilst the subsequent healing has advanced with a rapidity in some 
cases quite astonishing. The following is one of Mr. Lucas's cases: A stout, 
florid woman, aged fifty, had suffered from varicose veins for twenty years, and 
from ulcers for ten years. The ulcers for which she was admitted on Sept. 8th 
had been open for four years. At the time of her admission there were two 
irregularly oval ulcers occupying the front and outer side of the left leg. The 
anterior one was nearly seven inches in length, by three inches and a half in 
breadth ; the second, situated behind this, was two inches and a half in length, 
by three-quarters of an inch in breadth. The surfaces of the sores were deeply 
excavated, and sloughing in parts, whilst the edges were thick, raised, and 
everted. Under the use of chloral lotion the ulcers quickly became sweet and 
clean, and the cuticle spread over them with very great rapidity, even while 
the surfaces of the sores were still considerably below the level of the surround- 
ing skin. The smaller ulcer was completely healed within a fortnight, and at 
the time the patient reappeared all that remained of the large one was a small 
fusiform patch of healthy granulations, about half an inch in breadth and two 
inches in length, upon which a blue line of cuticle was rapidly encroaching. 
— Practitioner, Nov. 1875, from Lancet, Oct. 16, 1875. 



280 Progress of the Medical Sciences. [Jon. 

37. Excision of the Thyroid Gland. — Dr. Patrick Heron Watso.v. in an 
interesting comniuuicatiou [Brit. Med. Jonni., Sept. 2.t, 1875), after referring 
to the unfavourable opinion generally entertained of this operation, relate.s six 
cases in which be has performed it with a fatal result in only one of them, 

"The first case," he says, " whicli came under my own care, in whicii it 
seemed desirable to effect e.xtirpation of a portion of the thyroid, occurred in 
my practice in May, 1871. The case was one of a young lady, who for many 
years had been affected with a tumour of the neck. It was centrally situated, 
prominent, of the size of a China orange, moving with the trachea correspond- 
ing to its upper part, of a solid and elastic consistence. It was very disfigur- 
ing, and steadily increasing in size, and especially so within a recent period 
antecedent to her coming under my care. Recognizing its thyroidal nature, I 
advised its removal by operation. 1 hoped, in operating, to find it easily enu- 
cleated, as it had made its way through the interval between the sterno-hyoid 
and thyroid muscles, and had no lateral extension over the carotid sheaths. 
The early steps of the operation were easily and rapidly completed. 'I'hey con- 
sisted of a linear incision in the mesial line over the centre of the tumour, which, 
after division of the fascia, afforded a ready access to the tumour; and, by a 
few touches of the knife aided by the fingers, the whole prominent part of the 
tumour was exposed. But no sooner were the lateral attachments of the 
tumour severed upon the one side, than the blood gushed in a copious stream 
both from beneath the sterno-thyroid muscles and also from the margin of the 
tumour itself. The vascular connections, which had retracted, were after some 
trouble secured with u ligature of silk passed beneath the central mass of the 
tumour, and tied so as to occasion constriction of the mass, and staunch all 
further flow. 'J'o escape from further trouble from bleeding before dividing the 
lateral attachments of the tumour upon the opposite side, I passed preliminary 
ligatures beneath the superior and inferior thyroid vessels, and, having tied 
these ligatures, I completed the operation without further loss of blood. The 
patient, in spite of the loss of blood, made a rapid recovery. The effects of 
this method of controlling the circulation in connection with the thyroid gland 
led to my conceiving the idea of mediate deligation of the thyroids as a prelimi- 
nary step in the operation of extirpation of a bronchocele. 

•' I had not long to wait for an opportunity of putting my plan to the test of 
actual practice; for, in the course of the same mouth (May, 1871) a patient 
was admitted to my care in the Royal Infirmary affected with a multiocular 
cystic goitre. She had previously been under treatment, when a single cyst, 
of which the tumour then seemed to consist, had been tapped and injected with' 
iodine. This plan of treatment had apparently' checked the progress of the 
disease, but again it had enlarged, and, at the time of her admission, the swell- 
ing was of the size of two fists. The patient had further become anaemic, and 
affected with exophthalmos to a slight degree. 

"In operating in this case, I followed the same method as in the first instance 
just narrated, so far as opening the fascia between the muscles in tiie middle 
line. But instead of opening the fascial sheath of the tumour. 1 pushed the 
parts aside, so as to carry my forefinger and thumb over the margin of the 
tumour at its upper and right corner, and felt for the situation where the supe- 
rior thyroid passed upon the tumour. Recognizing these vascular connections, 
I introduced an aneurism needle beneath them. In this manner, I was able to 
withdraw a ligature beneath the right superior vascular connections of the 
goitre. The needle was similarly carried beneath the posterior surface of the 
right inferior corner of the gland, so as to include all the right inferior thyroi- 
dal connections, and a ligature similarly withdrawn beneath them. Tiie same 
process was repeated upon the left side, a ligature being carried beneath the 
left superior and inferior thyroidal connections. These four ligatures included 
not only the arteries and their corresponding veins, but the delicate fascial 
sheath which surrounds them, and, passing along thorn, forms the fascial in- 
vestment or fascial capsule of the tumour. The ligatures were then tied sepa- 
rately, so as to secure the vessels as far from the tumour as possible. The 
fascial sheath of the tumour having been now divided in the mesial line, the 
attachments were cut through with scissors, and the lunuuir turned out of its 



187G.1 Surgery. 281 

bed by strippinjj away the luscial capsule with the fiuirers. After tlie tumour 
had thus l)een enucleated entire, oue of the ligatures partially slipped, owiuo: 
10 its havinjr been unduly strained as a means of keepinij the soft parts sepa- 
rate. A push of blood took place into the cavity ; but this was at once 
checked by the pressure of a sponire until another li<jature was carried round 
the vascular connections of the tumour corresponding to the bleeding part ; 
when this was tied, all further bleeding ceased. The wound was closed by 
sutures, e.\cept at the lower angle, where a large drainage tube was inserted to 
secure the evacuation of all blood, serum, or other discharge, during the heal- 
ing of the wountl. The dressings were retained in position by means of a cravat 
composed of a muslin handkerchief foUUd upon a piece of buckram, after the 
manner of an old-fashioned stock. 'I'he skin, which at first hung loose and 
flaccid, had in two days so adapted itself to the parts beneath as to show no 
signs of redundancy. The wound, with the exception of the point where a 
ligature hung out, was healed in a fortnight. 

" The second case, one of multiple cystic goitre, was operated on in the Chal- 
mers' Hospital in the autumn of 1871. It presented no peculiarities in con- 
trast with the case just narrated. In it, catgut ligatures were used instead of 
silk, and were cut short after the removal of the tumour was completed. Here 
the healing process was completed in three weeks, and the patient, who had 
been sent to my charge by Dr. Howden, of Montrose, returned to her duties as 
an asylum attendant. In this case, the autemia and exophthalmos, which were 
present on admission, markedly diminished after the operation, 

"The third case was that of an Irishwoman, also affected with multiple cys- 
tic goitre. She was admitted to Chalmers' Hospital in the early part of 1872. 
'I'he operation was performed in exactly the same manner as in the last men- 
tioned cases, and was followed by equally favourable results. 

" 'I'he fourth case, a patient from Leith, was admitted to the Royal Infirmary 
in February. 1872. This was also a case of multiple cystic goitre. It had 
grown steadily for twenty-three years, having commenced at the period of 
puberty. It was of the size of a large fist; it pulsated distinctly, and was ac- 
companied by anaemia and exophthalmos. The operation was performed on 
March 1st, 1872, in precisely the same manner as already detailed. An anom- 
alous aneurismal condition presented itself after the healing process was com- 
plete, in the situation of the right superior thyroid. When first remarked, six 
weeks after the operation, it was about the size of a hazel-nut; but it gradu- 
ally increased until it became as large as a small walnut. It then presented 
all the characters of an aneurism with a venous communication, manifesting 
the peculiar rattling thrill and the hruit de diahle. After continuing lor about 
three weeks, it then disappeared gradually, no treatment beyond rest in bed 
having been employed. 

'• In addition to these, 1 have operated successfully upon two other cases, 
and with a fatal result in one case. In this fatal case, the tumour, of very large 
size, was adherent to the trachea. After the preliminary application of liga- 
tures and the division of the vascular attachments upon the right and left sides 
had been effected, on turning the tumour to one side, a large vein, lying poste- 
riorly in the groove between the trachea and the oesophagus, was unfortunately 
wounded. The pressure of the sponge applied to arrest its bleeding, together 
witb the drag upon the trachea when the tumour was turned to one side, inter- 
rupting the respiration, led me to attempt to separate the attachments of the 
tumour from the trachea rapidly by means of the knife in a deep wound, from 
which bleeding was still going on. The thin and soft posterior wall of the 
trachea thus turned outwards was unfortunately wounded ; and. before relief 
could be afforded by opening the trachea and introducing a tracheotomy-tube 
below the level of the tumour, so much blood had been sucked into the air- 
passages as to determine a fatal result in the course of the evening." 

Dr. W. considers his method of extirpating goitre an original one. It seems 
to us to differ from Dr. Green's (see No. of this Journal for January, 1871. p. 
80) mainly in his applying the mediate ligature to the thyroid arteries before 
opening the sheath ofthe gland, whereas the latter opened the sheath first, and 
then applied a ligature to the pedicle. 



282 Progress of the Medical Sciences. [Jan. 

In operatin<? by his method. Dr. W. recommend.s attention to the following 
particulars : — 

" 1. The external incision should be very free, extending from the larynx to 
the notch of the sternum, if the tumour be large and spread widely in a lateral 
direction. 

" 2. The vessels, arterial and venous, in the early steps of the operation, 
should be secured as they are divided, to avoid any obscuration of the parts 
through oozing going on. 

" 3. The fascia should be as freely opened as the skin ; and, if the tumour be 
a large one, more space may be gained by a transverse division of the soft parts 
as far as the margins of the sterno-raastoid muscles on each side. 

" 4. The delicate investing fascial sheath of the thyroid should be left undi- 
vided until the mediate ligature of the vessels included in their fine cellular 
sheath has been effected. This sheathing fascia or cellular capsule of the thy- 
roid gland is only a prolongation of the sheath of the thyroidal vessels. If 
the capsule be opened, then, in pushing aside the soft parts to disclose the out- 
line of the tumour, this delicate sheath is apt to glide off the surface of the 
gland ; and, should tins occur, the gland may readily be detached from the 
vessels even with comparatively gentle handling, and thus copious hemorrhage 
difficult of restraint may he occasioned. 

" 5. After the mediate ligature of the thyroidal vessels in their sheathing cel- 
lular envelope, the cellular capsule of the thyroid gland should now be opened 
by scratching through its tissue in the middle line, and the attachments which 
still i-etain the goitre in its position carefully divided by means of blunt-pointed 
scissors curved on the flat. There should be no tearing away of the gland, no 
pushing parts aside with any roughness of manipulation. 

"6. Should bleeding occur from any of the vascular attachments of the 
tumour after its separation, it must be remembered that it must occur from 
within the cellular sheath of the vessels, and find its way thence into the cavity 
consisting of the investing fascial capsule; and, therefore, if the vessels are to 
be tied, they should be secured en masse along with their cellular sheath. 
Without this sheath, furthermore, these enlarged thyroidal vessels will be found 
so fragile as to risk being cut by the ligature, while any attempt to reach the 
bleeding mouths within the fascial capsule will be baulked by the infiltration of 
this cellular envelope of the vessels by a coagulura." 

38. A Pistol Ball remaining eighteen days in (he Left Ventricle of the Heart. 

M. TiLLAUx exhibited to the Surgical Society of Paris (Nov. 3'd) the heart 

of a woman who had received two shots from a revolver, the ball being of 7 
millimetres. One of them was found in the diaphragmatic pleura of the right 
side, where it had caused an abscess of the liver. The other ball had traversed 
the right lung and penetrated the posterior parietes of the left ventricle, 
and was found in the interior of that cavity. This foreign body remained 
for eighteen days in the ventricular cavity without any symptom during life 
leading to the least suspicion of a lesion of the heart. Auscultation many 
times made by MM. Tillaux and Siredey srave no indication of it, and the 
pulse was always regular. There could be found scarcely a trace of the open- 
ing made by the projectile. The cicatrization was rapid and complete. M. T.. 
knowing that two balls had penetrated the chest, discovered the second merely 
by chance, after seeking for it in the lungs and mediastinum. — Gazette Hehdo- 
liiadaire df M6d. et de Chirurg., Nov. 12, 1875. 

[In the No. of this Journal for May, 1829, p. 263, will be found recorded a 
case of a boy, aged 15, who was shot in the rliest and lived for sixty-seven days. 
On post-mortem, three shots were found lying loose in the cavity of the right 
ventricle and two in the right auricle. In the number of this Journal for Aug. 
of the same year are some interesting observations on wounds of the heart, 
and an account of numerous cases of this injury, by Dr. John Redman Coxe.] 

39. Urethral Neuropathy. — Under this designation Dr. Brox describes one 
of the occasional consequences of gonorrhoea. As a general rule, he observes, 
after the discharge has ceased the patient regards himself as cured : but this 



1876.] Surirery. 2^'S 

is not always tlie case. There may siilisist or supervene a considerable amount 
of rnalaixe, the patient complaining of "lumbar lassitude, and a sense of heavi- 
ness in the hypojrustrio res^ion. The urethra becomes the seat of various 
painful sensations, difficult of description. Sometimes they simulate the 
symjitoms of stone or stricture, but are not of any ti.xed character, coming on 
and disappearinir at intervals not to be foreseen, and resisting all remedies. 
The rectum may also be painfully affccled, although no disease can be detected, 
and there is a sense of plenitude of the pelvis in general. These various 
symptoms, which are often conjoined with great disturl>ance of the digestive 
organs, are not all observed in the same individual, but are met with in differ- 
ent degrees in various patients — sonietimes being only very transitory, but at 
others alisolutely li.xed. and the occasion of great physical and moral suffering. 
The direct cause of this suffering is not always easily detected, for there 
may not be a single sign of the preceding blenorrhagia present, and it is chiefly 
the patient himself who insists upon this being the origin of what he sufliers, 
and often regards it as a proof that his malady has been imperfectly cured. 
M. Bron considers the seat of this suffering to be those portions of the uretiira 
which are narrower than the rest, and are consequently more sensitive to tlie 
passage of the urine. This sensibility becomes in these cases, after the sub- 
sidence of the acute symptoms, a true neurosis, which may long resist the 
remedies usually resorted to. He speaks unfavourably of mercury, bleeding, 
opiates, baths, blisters, etc., as either of no advantage at all or of only tempo- 
rary utility, and strongly recommends the passage of the bougie. Any chronic 
inflammation that may remain, and the spasm it gives rise to, are by this effect- 
ually relieved. He passes very gently on alternate days a small soft bougie, 
which is progressively increased in size, and is left in sita for only one or two 
minutes. lu a very short time the exaggerated sensibility of the urethra 
becomes modified, and the use of the instrument is repeated or not according 
to whether the symptoms recur. — Med. Times and Gaz., Oct. 9, 1875. from 
Lyon Medicate, Sept. .">. 

40. Chloral ns ati Application in Fissure of the Anus. — Dr. Crequy, writing 
to Dr. Dujardin-Beauinetz corroborating the statements made by the latter as 
to the great value of chloral (diluted to a twentieth) as an application to all 
kinds of wounds, adds that he has found it also of the greatest utility in two 
cases of fissure of the anus. The patient having had a stool a few hours before, 
either spontaneously or by aid of an enema, he introduces between the lips of 
the fissure a small tent of charpie consisting of about twenty fibres, and first 
soaked in the solution of chloral diluted to a fiftieth. This is left in until dis- 
charged during defecation next day. The first and second dressings are very 
painful, but afterwards they become less and less so, so that in a fortnight all 
pain has disappeared, and the fistula has cicatrized. — Med. Times aiid Gazette, 
Oct. 15. from Bull, de Th6rap., Sept. 30. 

41. Osteoclasis and Osteotomy from an Orthopcedic Point of View. — Dr. 
Nepteu (Archives G4n6rales de Midecine, September, 1875), after briefly 
noticing the history of osteoclasis, proposes especially to pass in review the 
practice of Billroth and Yolkman. 

Manual and mechanical osteoclasis have been employed up to the present 
time in cases of four different classes, viz., (1) badly united fractures; (2) 
articular deformities resulting from ankylosis ; (3) bent bones in rickety sub- 
jects ; (4) deformities resulting from old dislocations. 

Of the various methods of producing osteoclasis, the author deduces that, 
first, that of manual force, and next, that of Rizzoli, have been most frequently 
employed. 

lu his summary he states, under the head of " Dangers of the Operation," 
(1) the rupture may not take place at the desired spot, the operation then 
becoming useless; and (2) the operation may be dangerous if the pressure on 
the part to be broken have been great enough to cause accidents, such as 
sloughs and so on. 

Taking into account all circumstances, osteoclasis, when performed with 



284 Progress of the Medical Sciences. [Jan. 

judffment, is generally a beneficial operation. In the majority of cases the 
artificially fractured limb is in the same" state as a limb accidentally fractured 
subcutaneously. In the 108 unselected cases of osteoclasis referred to in this 
work there was not a single accident. 

The therapeutic results seem satisfactory in the treatment of deformities 
produced by ill-formed callus (De la Motte, 1G99, Dupuytren, Gurlt), and in 
rickety deformities (Volkmann, Billroth). In old dislocations, the operation 
only corrects a part of the deformity, the angular deviation (Volkmann). The 
rupture of bony ankylosis is sometimes sufficient to re-establish the normal 
position of the limb, but not always to restore mobility. Any attempt of the 
sort should be avoided, when the ankylosis is of very long standing, when the 
arteries are atheromatous, when the periarticular tissues are matted together, 
or when the bones themselves are much atrophied.— Lorido?t Med. Record, 
Nov. 15, 1875. 

42. On Resection of the Scapula. — Dr. Boeckel. in a communication made 
to a general meeting of the medical men of the Lower Rhine, and reported in 
the Gazette Medicate de Strasbourg for 1874, related two cases of resection of 
the scapula. One was a case of resection of the acromion and of the external 
third of the spine of the scapula. The cure was completed in two months, and 
the movements of the arm were perfectly re-established at the end of six months. 
In the second case there was caries of the scapula ; subperiostal resection of 
the scapula was performed, leaving the articular portion, and the inferior angle. 
Cure was effected in between two and three months. At the end of between 
three and four months there was complete bony regeneration, and at the end of 
six months use of the limb was restored. Dr. Boeckel thus describes the 
method of operation employed. 

1. Tegumentary incisions. A first transversal incision was performed, starting 
from the extremity of the acromion to the level of the fistuhe, that is to say, 
almost as far as the external third of the spine ; then instead of following the 
spine throughout its length, like the majority of surgeons, we got near to the 
upper edge of the bone, hoping in this way to thoroughly lay bare the upper 
part of the scapula and to protect ourselves against the objection made to the 
transverse incision of Langenbeck, Syme, etc., which but imperfectly uncovers 
the infraspinous fossa. It did not occur to us at the time that the caries could 
be so extensive, and we proceeded to rasp the acromion and the commence- 
ment of the spine by detaching the subscapular muscle and the periosteum 
from their attachments to the bone. This process was very easily performed, 
favoured by the slightness of the periosteal adhesions. When I came near the 
spinal edge I found this portion diseased. An incision, in the first instance 
perpendicular, keeping along the spinal edge, and reaching to the bone, was 
made over a space of a few centimetres ; but it soon became necessary to pro- 
long it on account of the caries, which extended further than had at first been 
supposed, so that finally there was a vertical incision nine centimetres long. 

2. Denudation of the bone was then proceeded with rapidly. I separated 
the muscle on the side of the infraspinous fossa, as far as above the coracoid 
notch, that is to say, until close to the base of the coracoid apophysis, without 
finding the subscapular nerve ; on the side of the infraspinous fossa the mus- 
cles were detached as far as two finger-breadths of the inferior angle, which 
was healthy ; the lov. er fibres of the infraspinatus were bisected ; the insertions 
of the teres major were left completely intact. I afterwards tried to raise the 
scapula and to roughen a portion of the subscapular fossa, in order to pass a 
chain-saw and leave the lower angle of the bone in the wound. A certain 
number of the fibres of the subscapularis were divided, and section of the bone 
was tlien performed. I was then enabled to lay hold of the scapula, draw it 
out of the wound, and lay it entirely bare. This process was easily performed, 
and was continued on the two surfaces almost as far as the glenoid cavity. As 
the vicinity of the cavity appeared relatively healthy, the chain-saw was passed 
through the coracoid notch, and the neck of the scapula was divided. At this 
moment, the subscapular artery gave out a strong jet of blood, and was taken 



187f).] Siirjrery. 285 

lip wiili miicli (lilliniliy, but iifttT smm' tinio was successfully tied. Tlie ampu- 
talidU was terminated l»y the division ol the acroinio-clavicular ligaments. — 
Ldtitli.u Mtd. L'tiuiil. Nov. 1."), 187'). 

4;{. Improvemeid on Syme's Operation. — 'I'his modification of Syme's em- 
ployed by Mr. Joskpii Bki,i, for three or four years, and practised in ten cases, 
he states [liiil. Mtd. Journ.. Oct. 2, iHTo) will, he believes. " be found to give 
the advantages promised by PirogoflTs method, and yet to avoid the risk of 
recurrence of disease of bone in the portion of os calcis left in Pirogoff's 
operation. 

" It is a very simple and slight modification, and consists in leaving attached 
to the flap the periosteum of the posterior part of the os calcis. and instead of 
dissecting the soft parts alone ott' the bone, stripping along with them the 
whole periosteum. In the case of amputation for disease of tarsus in children, 
this is done with the most perfect ease. It adds to the chance of vitality of 
flaps, diminishes the risk of sloughing and number of vessels to tie, and gives 
the most e.xcellent results. Especially if the patient be encouraged early to 
move his flap by means of the tendons which soon take on new adhesions, we 
find that a considerable power of moving the heel flap over the end of tibia is 
saved, and, in some cases, a deal of new bone is formed from the periosteum. 
So much so is this the case, that in one patient on whom I operated in 1874, it 
was hardly possible to persuade those who saw the stump, that it was not a 
portion of astragalus which had been left, with the integrity of the ankle-joint 
preserved. As all the cases in which 1 have practised this modification have 
survived and been successful, I have not found any objection to it, nor had the 
opportunity of making any post-ma r(>7n e.xamination. 

'• One case had to be taken down about the fifth day for secondary hemorrhage 
from the posterior tibial, yet 1 did not find tliat the presence of the periosteum 
implicated in any way the subsequent secondary union of granulations which 
healed the wound." 

44. Aortic Aneurism surcess/iiUi/ treated hy the Distal Ligature. — An in- 
teresting case of this is related by Mr. Thos. Annandalk [Brit. Med. Journ., 
Oct. HO, 187.o). The ])atient was a man set. 62, with a distinct aneurismal 
tumour, pulsating strongly, and passing up from behind the clavicle and sterno- 
clavicular articulation into the neck, as far as the cricoid cartilage. The tra- 
chea was displaced towards the left side by the tumour, and the inner half of 
the clavicle and its articulation with the sternum were pushed forward by the 
portion of the tumour under them. There was a well-marked hruit to be heard 
on all sides of the swelling, and there was dulness on percussion over a con- 
siderable area, corresponding to the situation of the thoracic part of the tumour. 
In addition to these symptoms, the patient had a constant irritating cough, 
pains shooting up into the head, want of sleep, and he was losing flesh mark- 
edly. Iodide potassium with rest were prescril)ed with some relief, but some 
time afterwards the symptoms returned and became more troublesome. After 
carefully considering the circumstances of the case, and determining that 
]iressure on the right carotid artery, immediately above the cervical portion of 
the tumour, very much diminished tlie aneurismal pulsation, it seemed to Mr. 
A. a favourable opportunity for practising the distal ligature. The position 
of the tumour did not permit the subclavian artery to be ligatured; but there 
was just sufficient room to secure the common carotid above the cervical por- 
tion of the aneurism. On the 2d of March, Dr. A. ligatured the common caro- 
tid immediately under the orao-hyoid muscle, which was drawn upwards, so as 
to reach the vessel. The internal jugular vein was unusually large and dilated ; 
and some care was necessary to avoid injuring it, as it completely overlapped 
the artery. The operation was performed under the carbolic spray, and the 
ligature used was prepared catgut. The immediate effect of the ligature was 
to almost stop the aneurismal pulsation, and to convert the strong pulsation 
into a kind of quivering motion. Not the slightest local or constitutional dis- 
turbance followed the operation ; and the wound was healed on the 17th. A 
week afterwards, the patient was out of bed. 'J'he day after the operation, the 



286 Progress of the Medical Sciences. [Jan. 

patient expressed himself as greatly relieved. He no longer himself felt the 
pulsation in the tumour, and the pains in his head and neck had disappeared. 
The pulsation in the aneurism was felt to be very feeble, and the tumour itself 
was decidedly smaller. 

The patient left the hospital a few weeks afterwards, his symptoms continu- 
ing in the same improved condition, and the tumour gradually becoming firmer 
to the feel. 

From time to time, the patient returned from the country to show himself, 
and his state on September 2Tth was as follows : His general health was 
good, and he had no pain or other uneasiness. He could stoop freely without 
giddiness, and could go up and down stairs easily. The tumour had continued 
to diminish in size, and its cervical portion was fully half an inch lower in level 
than before the operation. 'I'he wliole tumour had become much flatter, and 
also firmer to the touch. On placing the hand over it, only a very feeble pul- 
sation could be felt, but the pulsation was slightly stronger over the upper part 
of the cervical portion. A bruit, could still be heard on all sides of the 
tumour, but it was not nearly so loud as formerly. 

4.0. Ligature of Femoral Artery ivilli Carholized Catgut for Popliteal An- 
eurism. — Mr. Holmes read notes of this case before the Clinical Society, Nov. 
12th. The patient was a footman, aged thirty-four, who, three weeks before 
admission into St. George's Hospital, began to experience pain and stifi'ness in 
the left ham, followed, four days before admission, by swelling and oedema of 
the foot and ankle. There was no history of any distinct strain, and he had 
alwiiys enjoyed good health. Upon his admission into the hospital, there was 
found to be a swelling, about the size of a walnut, in the left popliteal space, 
pulsating strongly, and with well-marked lateral dilatation. There was neither 
thrill nor bruit in the tumour, and very slight pressure on the femoral artery 
caused the pulsation to cease and the swelling to collapse. At first, digital 
pressure was tried for twenty-two hours. This was attended by a very con- 
siderable diminution in the pulsation ; the tumour no longer entirely collapsed 
when the artery was compressed, and the sac appeared to contain a consider- 
able amount ol' soft coagulum, especially at its outer part. After an interval 
of twenty-four hours, during which an air-pad was applied to the tumour, digital 
pressure was resumed, and continued for six hours daily for three days. All 
pressure was then relaxed, and the following morning the pulsation was as 
distinct as ever. Various forms of instrumental pressure were now tried, viz., 
by means of a weight in the groin, and Carter's tourniquet; and a final effort 
by digital pressure, which was kept up continuously for thirty-one hours. As, 
however, all these means failed, ligature of the femoral artery was determined 
upon. Accordingly, on August 12, a stout ligature of carbolized catgut was 
applied to the artery at the apex of Scarpa's triangle. In the course of the 
operation, a small vein, lying to the inner side of the sheath, was wounded, 
and subsequently secured by a ligature. The wound was dressed according to 
Lister's antiseptic method, and the limb enveloped in cotton-wool. On the 
following day the patient was found to be going on favourably, except that 
there was a little tenderness along the course of the sapheua vein. On the 
14th, two days after the operation, no pulsation could be felt in the tumour or 
the arteries of the limb. The foot was warm, with the exception of the ex- 
tremity of the grert toe, which was cold and of a slightly dusky hue. The 
dressings were changed; the wound looked healthy; there was no redness and 
no appearance of suppuration. There were swelling and tenderness along the 
course of the sapheua vein, but no redness. The man went on well until the 
evening of the 16th, when the house-surgeon was called to him, and found him 
suffering from undoubted intoxication ; he was talking rapidly and incoherently, 
at intervals shouting out loudly for drink, and endeavouring to strike those 
who came near him. It appeared that his friends had smuggled in a quantity 
of gin, which he had drunk. On the following day he was in a peculiar condi- 
tion, half-stupid, with a frightened expression of countenance, answering ques- 
tions very hurriedly and not to the purpose, and tossing about in bed in a 
restless manner. He continued much in the same state till the IDth, gradually 



187G.] Surgery. 287 

sinkinfr, with muscular t\vitcliiu<r of the limb, incolieroncc of spcecli. pickinsr at 
the bed-clothes, a browu fuirtd touf^ue, and sordes on the teeth. JIo died 
quietly at about 1 V. M. Mr. Holmes stated that he luul brought forward this 
case with a view to comparin": the relative advantages of silk and catgut liga- 
tures for tying the larger arteries in their continuity. His own experience 
had not been enough to justify him in expressing a dogmatic opinion, as he 
had only applietl the cattrut ligature to four of the large arteries in their con- 
tinuity, viz., to the subclavian and carotid, which were tied simultaneously for 
thoracic aneurism, and in which the man died eight weeks afterwards from the 
result of galvano-puncture ; thirdly, to the femoral artery, as al)Ove narrated ; 
aud, fourthly, to the left carotid, in a case upon which he had operated twenty- 
two days ai;o. In the first instance the vessels were found to be closed by a 
kind of diaphragm of no great extent, and neither of the vessels had been cut 
through. In the second case, that of the ligature of the femoral, of which the 
notes had l)eeu read in exteiisn, the artery was shown to the members present. 
The knot of the ligature was visible; but there was nothing to be seen of the 
rest of the string. The artery was perfectly continuous. In the fourth case 
there had been free suppuration from tlic wound ; but now, on the twenty- 
second day, there was no irritation about it, and no part of the ligature had 
come away. Such, Mr. Holmes stated, was his experience with the carbolized 
catgut ligature, and the results, though far from conclusive, were quite con- 
sistent with the opinion which he entertained that the antiseptic ligature was a 
most eflBcient agent in combating the tendency to secondary hemorrhage, and 
that it rendered possible that union by first intention which was John Hunter's 
object in his first operation on the femoral artery. 

Mr. Holmes simply brought forward the cases as examples of catgut liga- 
ture, the action of which did not depend on the absence of suppuration, but 
rather on its effects on the vessel. The ligatures might melt away, and pulsa- 
tion return; but he believed the important thing to be that they did not of 
necessity divide the vessel. 

Mr. Callender said that it was pretty well known that he did not use Lister's 
antiseptic method, but his own. In three cases where catgut had been applied 
at St. Bartholomew's, hemorrhage had followed. In one case a young patient 
in good health had the femoral thus ligatured, and the wound was drained by 
keeping in it a piece of catgut. On the tenth day pulsation returned ; by and by 
the draining catgut came away in half — the remainder had melted. Next came 
a gush of blood, and the patient died of iiemorrhage after amputation at the 
thigh. No ligature was to be seen round the artery. Beneath the site of the 
knot was the fatal opening, where the walls must have been contused, and 
sloughing had followed. — Medical Times and Gazette, Nov. 27, 187.5. 

4G. Carhnlized Catgut Ligature. — The following is the method of preparing 
this ligature. The material is really a part of the peritoneum of the sheep, 
with some fibres of unstriped muscle. This, having been properly cut into 
lengths and sizes for ligatures, might be simply dried and used, or used fresh, 
but in either of these conditions it is slippery, hard t) tie, and when tied apt 
to stretch, and the knot to slip. Mr. Lister, anxious to procure a ligature 
which should melt away aud be absorbed without acting as a foreign body in 
the wound, and looking to the somewhat unsatisfactory experiences of Astley 
Cooper and others, found thtit by a special preparation this catgut was so 
altered as to become a firm and useful ligature. If it is suspended in an emul- 
sion of oil and water, during the first few days it becomes dull and opaque, but 
then a remarkable change occurs : it becomes clear, bright, and hard, and 
capable of being tied witiiout stretching and slipping. In order to attain this 
changed condition it is necessary to keep it suspended in the emulsion for 
about two months, the bottom of the vessel being so arranged that the water, 
as it separates from the oil, falls down clear of the suspended catgut. It will 
be ready in two months, but it goes on improving if kept in the emulsion for a 
much longer period. In order to make a very fine emulsion, the water was 
mixed with something which the oil would take from it — say spirits of wine — 
and the water was thus left suspended amongst the oil in very minute drops. 



288 Progress of the Medical Sciences. [Jan. 

Mr. Lister wished to have an antiseptic liffatnre. anrl he found that carbolic 
acid ha<i the requisite properties for forming along with water and oil the 
re(]uirod fine emulsion. Hence the rarbciized catgut ligature. — Ibid. 



OPHTHALMOLGY. 

47. On (he Function of the Ciliary Muscle. — In conjunction with Dr. Nuel, 
of Luxembourg, Dr. Warlomoxt has contributed an elaborate account of the 
ciliary muscle to the Jiictionnaire Enryclop^diqne cles Sciem-cs Medicales ; 
and the entire article is to be found in the Annales d'Ocidistique {}iVdy and 
June. 187.")). The anatomical relations of the muscle, as a whole, and the 
arrangement of its two principal sets of fibres, are elaboratelj' illustrated in the 
first portion of the article. Before stating his views on the function to be 
assigned to these different sets of muscular fibres, Dr. Warlomont quotes the 
opinion of Dr. Giraud-Teulon upon this very point, which is to the effect that 
no hypothesis has as yet served to e.xplain the e.xact role played by the ciliary 
muscle in producing the convexity of the crystalline lens ; and he himself was 
unable to aid in clearing the obscurity. Since Giraud-Teulon wrote as above, 
ten years have elapsed, and still the problem is unsolved ; and while Warlo- 
mont agrees with Giraud-Teulon in considering the theory propounded by 
Helmholtz, and now generally received as the most probable, yet he is of tiie 
opinion that it only partly explains the facts as they occur; and he thinks it 
highly probable that the relaxation of the suspensory ligament, and the conse- 
quent increase in the convexity of the crystalline lens, are due to the action 
of the circulur fibres alone; and that it is the function of the radiating fibres 
to antagonize the circular fibres, by again putting the suspensory ligament on 
the stretch, and by restoring the somewhat flattened condition of the lens. 
Although he admits this to be an hypothesis, Dr. "Warlomont thinks that the 
functions of the ciliary muscles are analogous to, if not identical with, those of 
the iris; and that, although the power of accommodation is compatible with 
absence of the lens, as a rule the two structures perform their functions in the 
same manner. The probability of this being the case is due to the fact that 
the innervation of the two structures is through the same nerves ; so that in a 
state of health the accommodation takes place pari passu Yiiih the movements 
of the iris. As exceptions to this, there are some diseases of the spinal cord 
in whicl) there is persistent action of the iris, although the power of accommo- 
dation is completely abolished. 

Very remarkable differences have been shown to exist between the ciliary 
muscles of eyes which were myopic and those which were hypermetropic 
during life, and they are relied upon by Dr. Warlomont as supporting his 
theory; and while he adopts the general opinion that there is no such power 
as that of negative accommodation — adaptatitm of the eye for distant objects — 
he yet holds it impossible that the accommodation can under these circum- 
stances be absolutely relaxed, inasmuch as the muscular tonicity still remains, 
and must be taken into consideration. 

" It has been objected," says Dr. Warlomont, '• that, as the radiating fibres 
of the muscle, when in action, form an arc with the convexity inwards, a sepa- 
ration of the muscle from the sclerotic must take place alter each contraction, 
and that, unless the space so formed be filled by some fluid or other, the 
pressure of the atmosphere would prevent any action of the muscle whatever." 
And, in answer to this objection, he asks whether it is clearly proved that 
there is any such separation between the muscle and the sclerotic ? or whether 
it is quite clear that the sclerotic does not follow and adapt itself to all the 
movements of the muscle, which must, in any case, be of very limited extent? 

In concluding this jmrt of his subject. Dr. Warlomont admits that he also, 
like Dr. Giraud-Teulor, before him, can throw but little light upon this con- 
fessedly obscure problem in phvsiolouical optics. — Loudon Med. Herord, 
Nov. 15, 1875. 



1876.] Midwifery and G yruv^cology. 289 

48. Tumojtrs t,f the Orhii. — Mr. <i!e(). Lawsijn c.\liil)ite(l to the Clinical So- 
ciety of Loiuloii (Nov. 20, 187;")) two pationts, from each of whom he had re- 
moved a tumour of the orbit. The cases were essentially different ; but each 
presented points of preat clinical interest. The first case was that of an elderly 
woman, who was admitted into the .Middlesex Hospital with a large melanotic 
tumour, involving the eye, and fillinj,^ up the whole orbit. 'I'his growth Mr. 
Lawsou removed, and then applied the chloride of zinc paste, and in such a 
manner thut he succeeded in saving the upper eyelid. One of the great dis- 
advantages, he remarked, of the use of the chloride of zinc in sucli cases had 
been that, owing to the running of the paste into the cellular tissue of tlie eye- 
lids, both lids had been destroyed by it. 'I'lie plan wiiich he now adopted, 
when practicable, was tlie following. After tiie eye and tumour had been ex- 
cised, pressure was made in the orbit until all bleeding had ceased. The mouth 
of the conjunctival bag, from which the globe had been enucleated, was then 
held open with two pairs of forceps, whilst the chloride of zinc paste spread on 
small strips of lint was plastered round the sides of the orbit. A small piece 
of cotton-wool was ne.xt introduced to keep the strip? of lint in sifu. and the 
mouth of the conjunctival bag was closed over the whole by a single continued 
suture. A layer of lint was then placed over the conjunctiva, and upon this 
the lids were closed and kept in position with a compress of lint and a roller. 
The patient progressed well, and had suffered no ])ain, and had no recurrence 
of the disease since she left the hospital on May 'J.ith. In the second patient, 
Mr. Lawson removed a tumour from within the orbit without inflicting any in- 
jury on the eye. The growth occupied the floor of the orbit, and seemed to 
spring from tlie periosteum far back in the orbit. It was about the size of half 
a walnut, much flattened where it was pressed between the eye and the orbit, 
but rounded at its free external border. The specimen was examined by Dr. 
Coupland of the Middlesex Hospital, who pronounced it to be a lymphoma. — 
Brit. Mtd. Journ., Dec. 4, 1875. 



MIDWIFERY AND GYNECOLOGY. 

49. Prevention and Management of Miscarriages. — Dr. A. W. Edis states 
{Brit. Med. Journal, Nov. 27, 1875) that it has been his lot to observe num- 
berless instances where miscarriage after miscarriage has been allowed to take 
place without a vaginal examination ever having been resorted to, or any at- 
tempt made to ascertain the causal condition of this premature expulsion of the 
ovum ; no instructions having been given to the patient as to what precautions 
should be taken to avoid similar catastrophes, no injunctions as to resting in the 
horizontal position, or \iv\ug absque marito until the process of involution has 
had time to be accomplished ; in fact, the whole affair being treated as if it were 
not worthy of serious consideration by the practitioner, or of any moment to the 
patient. 

In a series of nearly 2000 cases of his own hospital patients at all ages, 
where the facts had been carefully recorded, there were no fewer than 1147 
miscarriages compared with 4588 children born at full time — a proportion of 
exactly one in four. This ratio Dr. Edis finds to be as nearly as possible the 
same among his private patients, the increased development of the nervous 
system among the upper and middle classes compensating for the diminished 
risk from the accidents which afiect the poorer classes. 

In the large majority of cases of miscarriage, they will be found to be due 
to some deranged state of the mother's health, or to some morbid condition of 
the uterus or its appendages. There are also many what may be called acci- 
dental causes, such as blows, falls, sudden agitations from fright, etc., which dis- 
turb the equilibrium of the circulation or strongly affect the nervous system. 
These are self-evident, and will not be here further referred to, inasmuch as, 
beyond enjoining avoidance of all unnecessary risks when patients are in the early 
stage of pregnancy, we can scarcely regard these as preventable causes. Dr. 
No. CXLI.— Jan. 1876. ly 



2:>0 Progress of the Medical Sciences. [Jan. 

Edis is anxious rather to direct attention to the unnecessary waste of life re- 
sultinj; from the frequent recurrence of miscarriages in the same patient, wliere 
there is some deranged condition of the uterus or its appendages : causes that 
may be termed preventable. 

The hope of preventing the recurrence of miscarriage depends upon our 
tracing out — what in every case exists — the efficient cause of it. 

50. Uncontrollable Vomiting of Pregnancy cured by Hyoscyamin. — Dr. 
PiTois, Professor at the Medical School at Renues, reports two striking oases 
of this. After trying unsuccessfully all the usual means, it occurred io him to 
administer a teaspoonful every hour of a mixture containing 5 milligrammes 
of hyoscyamia in 125 grammes of fluid. The next day the vomiting ceased, did 
not recur, and the patient went on favourably to the natural term of her preg- 
nancy. A second case of the same kind was cured by the same remedy. — 
L' Union Medicate, Sept. 14, 1875, from Journ. de M6d. el de Chirarg. Pract., 
July, 1875. 

51. Rapture of Uterus — -Baxdl has given his views on this subject, founded 
on thirteen cases observed by himself, and nineteen extracted from the records 
of the lying-in wards of the Vienna hospital. To begin with, a pathological 
change in the substance of the uterus, which has been so generally accepted 
as a predisposing cause, especially in multiparse, was not found in a single 
case. The uterus was invariably thick, well contracted, situated high, the 
cervix unusually thin. The fissure v/as found mostly in the cervix, or began 
there when the body of the uterus was also torn. The peritoneum was sepa- 
rated only in the lower parts, never from the fundus. A predisposition from 
disease of the uterine wall. Baud! doubts absolutely, and believes the final cause 
of the rupture to be always in disproportion ; in his thirty-two cases there were 
nineteen of narrow pelvis, three of hydrocephalus, eight of shoulder presenta- 
tion, one prolapse of the foot with the head, and only one case remained unex- 
plained. Nor did pressure produce rupture, as he frequently found sloughing 
without rupture — in one case even both were present, but at different points. 
An unyielding os uteri, rudimentary or double development, fibroid tumours, 
are often adduced as causes, but not proven to be so. Like Chiari. Braun, 
and Spaeth, Bandl considers the predisposing effect of want of proportion 
increased by the want of equilibrium between a highly developed muscular wall 
and a thin cervix; and as he found by measurement that the uterine wail in 
multiparaj, especially when there had been disproportion in previous labours, 
was much developed, he believes the abnormality to consist in an excessive 
thinning of the cervix taking place during labour. 

In normal circumstances, the passive cervix is drawn back over the head of 
the child by the muscular uterus ; the orificium internum remaining, as investi- 
gations on the living, and dissections on the dead subject show, about the level 
of the brim of the pelvis. But if there exists a disproportion which does not 
allow the presenting part to descend into the pelvis, the cervix is abnormally 
stretched, the internal orifice is raised a handbreadth above the brim, and so 
rupture becomes possible. If this abnormal condition has once existed, it takes 
place again more easily in future labours, which is the reason why ruptures 
take place more frequently in multipariE. 

Bandl believes that rupure can be recognized as threatening when the orifi- 
cium internum gradually ascends, whilst the cervix stretches and the fundus 
acquires a lateral position. — Edinb. Med. Journ., Oct. 1875, from Centralblatt, 
No. 33, 1875. 

52. General Dropsy in a Fochis. — Mr. L.\w.sox Tait related to the Obstet- 
rical Society of London (Nov. 3d) the particulars of a case of this in which 
the skin was so tense that it was not possible to bend the limbs without risk 
of bursting the skin. The scalp was so distended that the bones could 
nowhere be felt, and, in fact, the head had been mistaken for the breech during 
labour. 'I'he abdomen was enormously distended by highly albuminous fluid, 
as also the pleurte and pericardium. The placenta was large and very edema- 
tous. The cause of the general dropsy seemed to be the premature closure of 



1876.] Midwifery and Gynivcolojry. 291 

the cliniini'l l)otwocu tlio aiirirles, there being uo (Hrect oponiuij between the 
aurieh'S tliroiiirh the foramen ovale. 

Dr. Snow Heek remarked that he had the opportunity of examinin<r both 
Pr. Smilli's ca.«es. and had also seen two other very similar specimens. The 
clioieal histories had l)een very mneh alike: healthy liviii;,' cliildren at first, 
then premature e.xpulsion of dead foetuses about the si.xth month, presenting 
evident signs of previous and serious disease. Effusion of fluid into the 
peritoneal cavity existed in all. far tcto large in quantity to be tlie result of 
post-mortem change. 'I'he organs, excepting the liver, were healthy ; this was 
paler than normal, soft, readily torn with the finger; the liver-cells being 
much broken down. The parents were singularly free from even the suspicion 
of a syphilitic taint. 'I'he effused fluid was too large and too generally diffused 
to be caused l)y any mechanical disturbance of the circulation. The only 
probaltle explanation of this condition of the fcctns appeared to be from some 
deficient or altered state of the nutrition, whether foetal or maternal it ap- 
peared impossible to determine from the facts at present known. — Luncd, Nov. 
27. 1875. 

53. The Dyfsmenorrhceal Membrane. — Dr. P. Finkt.kr, of Kiew. has e.xamined 
seven specimens of dysmenorrhoeal membrane obtained from four patients. 
One of these was under observation in the hospital for three months. During 
that period she menstruated three times, and passed a membrane on each occa- 
sion. Dr. Finkler believes that the membrane is the mucous membrane of the 
uterus, inclusive of the blind extremities of the glands, but that in some cases 
the deeper layer of the mendjrane and the terminations of the glands remain 
in the uterus. The structure of the seven membranes examined was essentially 
the same, but with varying proportions of blood, round cells, and epithelium, 
and similar to what had been described before as the structure of the uterine 
mucosa during the early part of menstruation. The names " apoplectic," "' vil- 
lous," "inflammatory." which have been given to different states of the mem- 
brane by different authors, depend on the ciuantity of blood, and granulation or 
round cells, found in the tissue; the villous character of the membrane depends 
on strings of fibrine which, in some cases, appear attached to its inner surface. 
The membrane is the product of disease, and not of impregnation and abortion, as 
was shown by the case referred to above. Nor is it the product of the increased 
physiological action which takes place in the generative organs periodically ; 
but it is the result of a pathological condition which is to be looked for in the 
character of its elements, in the g^eat accumulation of granulation cells, many 
homogeneous, others granular, some nucleated ; in the blood and fibrine found 
in the tissue ; in the epithelium swollen, glistening, or lost in the flocculent 
outer surliice of the membrane ; persistence of the disease, its recurrence after 
cold, aiiortion, labour, acute inflammation of the uterus itself, its false position 
and abundant flow of mucus (often with acid reaction) from its cavity. All the 
meml)ranes examined gave the amyloid reaction with iodine and sulphuric acid, 
and Dr. Finkler thinks this is probably the real pathological condition. The 
cause of separation of the membrane he finds in the accumulation of granulation 
cells in the mucous and submucous tissue, and in the flow of blood, which in 
some cases takes place into the whole of the mucous membrane, and in others only 
into the deepest layer of it ; in consequence of these two forces the mucous 
membrane becomes detached, acts like a foreign body, and excites uterine con- 
tractions. — Lancd, Oct. 9, 1875. 

54. Peri-uterine Hcematocele after Abortion. — A case of peri-uterine hfemato- 
cele, a sequence of abortion, is related by Dr. S. Schrank, in the Med. Chirurg. 
Cevtralblatt for July 23. The patient was not aware she was pregnant, although 
about three months had elapsed since she menstruated last. Three days previ- 
ously to her observing a discharge of blood from the vagina, she had slipped down 
a couple of stairs. Homely measures failing to arrest the flow, she applied 
for medical relief. Vaginal examination showed the uterine cavity to be empty, 
the OS readily admitting one finger. Vaginal injections of iced water were 
ordered, and 50 centigrammes {1^ grains) of ergot to be taken every hour, and 
cold compresses to be applied over the abdomen. The patient was somewhat 



292 Progress of the Medical Sciencbs. [Jan. 

overcome from her loss. During the ni^ht there were a few occasional gushes 
of blood, mixed with portions of the decidua. When seen next day she was 
extremely blanched, and any movement caused faintings. A digital examina- 
tion discovered a few coagu'la in the vagina, and the uterus was full of them. 
External palpation revealed a swelling of considerable size, distended, and 
neither painful nor tender on pressure. No connection could be made out by 
examination through the abdomen and vagina between it and the uterus. The 
suddenness of the appearance of the tumour, the collapsed condition of the 
patient, although there had been external hemorrhage, and the non-connection 
of the tumour with the uterus, indicated the existence of an hematocele. The 
blood evidently, instead of escaping j;e/- vaginavi, had, from some pathological 
or abnormal condition of the Fallopian tubes, passed backwards into the 
abdominal cavity, giving rise to an htematocele. It is a rare accident for any 
fluid to pass from the uterine cavity through the Fallopian tubes into the peri- 
toneal cavity without some impediment to its exit ; still there are several 
recorded cases of uterine injections doing so. Considering how frequently 
iutra-uterine injections have been used, and how rare has been the accident, 
the author inclines to the belief that it only occurs under some pathological or 
abnormal condition of the Fallopian tubes and ovaries. — London Med. Record, 
Nov. 15, 187.5. 

55. Ovariotomy complicated vjitli Pregnancy and Ctesarean Section. — Mr. 
Thomas Hillas records the following case of this. The subject of it, set. 24, 
single, was admitted into the Balarat District Hospital on June 4, 1872, having 
previously' been in another hospital for supposed pregnancy, and been discharged 
after a seven months' residence as suffering from ovarian tumour. After ad- 
mission at the Ballarat District Hospital, she was examined by the staff, and a 
consultation held, when ovaritomy was decided on. On June 13th, Mr. Hillas 
commenced the operation, and, in entering the peritoneal cavity, cut into a gravid 
uterus. The abdominal incision being enlarged, an ovarian tumour was removed, 
and the clamp applied to the pedicle ; the uterus all this time lying on the 
thighs, with a wound probably into the placenta. The general advice was to 
sew up the wound in the uterus, and let nature take its course ; but Mr. 
Hillas. thinking labour must soon come on, and fearing rupture of the uterus at 
the wounded point, decided to perform Csesarean section. The uterus was in- 
cised to five inches; a-ud the placenta, with a living and well-developed foetus 
at about the eighth month, extracted. Nine or ten silver sutures were then 
put into the uterus, the cut ends being carefully tucked down into the incision. 
The uterus immediately firmly contracted. The abdominal wound was then 
closed with deep and superficial stitches, the clamp at the lower angle of the 
wound having a good deal of drag on it. The patient vomited for forty-eight 
hours after the operation. In four days, all unfavourable symptoms ceased, 
and she was discharged cured at the end of six weeks. On July 3d, a mouth 
after the operation, she menstruated moderately for four days ; and again on 
August 28th. She has since been seen several times in good he;Jth. [The 
success attending ovariotomy during pregnancy, without interfering with the 
uterus, is well established by many successful cases. The above case seems to 
show that we need not be in despair if such a very unfortunate accident as wound 
of the uterus occur. It would be very interesting to have the further history 
of the silver sutures, especially should the woman again become pregnant.] — 
Bril. Med. Journ., September 25, 1875, from the Austrcdiau Medical Journal, 
Feb. 1875. 

56. Use of Chloral Hydrate in Carcinoma Uteri. — Dr. Fleischkr recom- 
mends the use of chloral hydrate locally in carcinoma uteri. After thoroughly 
washing out the vagina, he passes up to the cancerous surface a piece of cotton- 
wool dipped in a solution of chloral hydrate (two drachms to three ounces); 
this is repeated every two hours. After two or three applications the character 
of the pain is altered, and the discharge becomes less oS'ensive. He prefers 
administering chloral as an anodyne by the rectum rather than by the mouth; 
its effect can be better regulated, and it does not confine the bowels as mor- 
phia does.— Brit, and For. Med.-Chirury. Rev., Oct. 1875, from Med. Chir. 
Centralblatt, ix. 1875. 



1876] 293 



AMERICAN INTELLIGENCE. 



ORIGINAL COMMUNICATIONS. 

Medico-ler]al Evidence of Independent Life in a New-born Child. By 
J. R. Gaston, M.D., of Montf^omery, Ala. 

Tlie jiresent status of medico-leijal opinion in rejj^ard to the siijtis of 
independent life in a new-born child, is shown l)y the testimony of nicdical 
experts, and the judgments of courts, both American' and English,- in 
two law cases which involved the statutory descent of large amounts of 
property. 

It appears that both English and Amercan courts agree that the beating 
of the heart of a new-born child, after the severance of the uml)ilical cord, 
is conclusive of the independent extra-uterine life of the child. This 
judgment of the courts depends upon the testimony of medical experts, and 
it is therefore clearly within the province of medical criticism to inquire 
whether the decision is or is not consistent with a just interpretation of 
the pjienomena of organic and animal life. 

Of the great functions of organic life, respiration and circulation appear 
to be the conditions most unremittingly essential to the life of the higher 
orders of animals. Resjiiratiou, which, in general terms, is the evolution 
of carbonic acid from the fluids of organized beings and the absorption of 
oxygen from the surrounding medium, exists alike in the vegetable and 
animal kingdoms. All plants and all animals [)erform essentially the 
same respiratory function. It. is an essential of organic life. (See Car- 
penter's Circulation, Gompar. PIvjs., pp. 253, 298.) The contrary is not 
an essential of organic life. The simplest organisms, both animal and 
vegetable, have no circulation whatever. Every part of their surface being 
equally capable of absorbing liquid nutriment, there is no necessity for a 
circulation. 

Medical gentlemen, in testifying that the beating of the heart after the 
severance of the umbilical cord is conclusive of the independent extra- 
uterine life of the child, have overlooked that function, res])iration, which 
is always and everywhere essential to organic life, and have given undue 

• A full accor.nt of tlii.s case, tried in Delaware, will be found in the Moul/Jy 
Abstract of Medical Science, for July, 1S75, p. 333. 

2 Tlie following is an abstract of this case : " A case of great interest in medical 
jurisprudence (case of Brock r. Kellock) has recently been decided by the Vice- 
Chancellor, Sir J. Stuart. The point at issue was to determine the legal evidence 
of life in an infant. Dr. Robert Lee and Dr. F. H. Ramsbotham contendeil that 
the proof of respiration having been performed was necessary to establish the 
fact of extra-uterine life. Dr. Tyler Smith, Dr. Freeman, and Dr. Alfred Taylor 
deposed that the continuance of the heart's action after severing of the umbilical 
cord must be accepted as proof of independent life. The Vice-Chancellor, in his 
decision, confirmed Dr. Tyler Smith's view of the case, and expressed his sur- 
prise that a man in Dr. Lee's position should have made such an affidavit. There 
was a large pecuniary amount involved in the decisioli. The case is of great 
importance, as it will serve to establish the law, which has been much unsettled 
upon the point at issue." 



294 American Intelligence. [Jan. 

importance to a function which is not an essential of orj^anic life, and 
which is found only amongst plants and animals of a somewhat complex 
differentiation of organs. That heart-beat is an essential of e.xtra-nterine 
human life, of course no one will deny; but I do deny that it is Ihe 
esf<enlia} upon the presence of which can be predicated independent extra- 
uterine life. 

Hityh medical authorities — Drs. Penrose, Paji-e, and others of this 
country, and Drs. Tyler Smith, Freeman, and Alfred Taylor of England — 
tell ns "that the continuance of the heart's action after severing of the 
uml)ilical cord must be accepted as proof of independent life." The fact 
is, however, that intra-uterine life, so far as heart-beat is concerned, is just 
as independent of the mother as extra-uterine life. The foetus is dependent 
upon its mother not for heart-beat and circulation, but for oxygen and 
nutrient materials. The foetal heartbeat and circulation, as such, are as 
independent and distinct as the adult heart-beat and circulation. Not so 
witii res))iration. For the performance of this function the foetus is en- 
tirely dependent upon its relations with its mother. Of the great organic 
functions, the suspension of any one of which would place life in imme- 
diate and imminent danger, none is so differentially characteristic of foetal 
life as placental respiration. Destroy it, and intra-uterine life must end. 
What i)hicental respiration is to the foetus, pulmonary respiration is to the 
infant. When the former ceases, an essential of intra-uterine life ends. 
When the latter is established, a .wie qua non of extra-uterine life has 
been supplied. Heart-beat and respiration are such absolute essentials of 
advanced foetal and extra-uterine life, and death follows so suddenly and 
surely the destruction of either of these functions, that I conceive the true 
doctrine to be that no child can be known to be alive in which either cir- 
culation or respiration has been destroyed ; and consequently since birth 
involves the s|)eedy destruction of placental respiration, that independent 
extra-uterine life cannot be affirmed of an infant which has not l)reatlied. 
Heart-l)eat is essential to both intra-uterine and extra-uterine life, but it 
is not characteristic of either. So it is with respiration ; but placental 
res)>iration is characteristic of intra-uterine life, and pulmonary respiration 
is characteristic of extra-uterine life. At birth no sign can be conclusive 
of independent extra-uterine life which is not characteristic of extra-uterine 
life. But does not division of the cord give to heart-beat a characteristic 
and independent function which it did not possess before ? I think not. If 
from a railroad train in rapid motion the engine should be detached, would 
not the brief, continued motion of the train be entirety dependent upon its 
recent relations to the engine ? Division of the cord cuts off, so far as 
the mother is concerned, a further supply of conditions of life ; but it does 
not give independence of life. I hold that the ])henomeiia observed in the 
children mentioned in the Delaware and English law cases, if they were, 
and so far as they \v'ere signs of life, were in the same measure dependent 
upon recent relations to the mothers, as were similar signs before division 
of the cords. 

In the children above mentioned, and in all like cases, there is good reason 
to believe that the heart's action should not be relied upon as a strictly 
test sign of animal life. The first of the i)ermanent organs of the embryo 
to display functional activity, the heart, pulsates while its walls are still in 
a cellular condition, before the formation of its own mu.scular tissue, or the 
development of nerve tissue either in its own substance or in the body at 
large. It beats through life so constantly, and so regularly, that we can 



1876.] Original Conininnica tions. 295 

almost "count time l)v heart tin'ol)s ;" and ]iliysiolofjists, however they 
may dilTer as to the theory, a<rree as to tlie faet that it may continue to 
beat after death. Nay more, Mr. TixM has siiown, contrary to what niijjht 
be expected, that this power of rhytlimical contraction after death is espe- 
cially persistent in very yonnj; animals. The independence of the heart's 
action has l)een demonstrated l)y numerous experiments. In some cold- 
bhrnded animals it will continue to heat for many hours after its re